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MANUAL 


OF 


Clinical  Diagnosis 


BY 


Dr.    otto    SEIFERT     and     Dr.  FRIEDRICH    MÜLLER 

PRIVATDOCENT  IN  wORZBURG  ASSISTENT  DER  II,  MED.  KLINIK   IN   BERLIN 


THIRD  EDITION 


REVISED   AND    CORRECTED    BY 

Dr.  FRIEDRICH   MÜLLER 


TRANSLATED,  WITH  THE  PERMISSION  OF  THE  AUTHORS,  BY 

WILLIAM  BUCKINGHAM  CANFIELD,  A.M.,  M.D.  (Berlin) 

Fellow  of  the   American  Academy  of  Medicine  ;    Member  of  the   Medical   and  Chirurgical 

Faculty  of  Maryland  ;   Visiting   Physician  to  the  Union  Protestant  Infirmary 

of  Baltimore  ;  Lecturer  on  Normal  Histology,  and  Chief  of  Clinic  for 

Throat  and  Chest,  University  of  Maryland. 


WITH  SIXTY  ILLUSTRA  TIONS 


NEW    YORK    &    LONDON 

G.    P.    PUTNAM'S    SONS 

%\t  Knickerbocker  ^rcss 

1887 


COPYRIGHT 

G.  P.  PUTNAM'S   SONS 


Press  of 

G.  r.  Putnam's  Sons 

Aevv  York 


TO   HIS   ESTEEMED   FRIEND 

PROFESSOR  H.  KNAPP 

THIS   WORK    IS   DEDICATED   BY 
THE  TRANSLATOR 


Ul 


PREFACE  TO  THE  FIRST  EDITION. 


The  presentation  of  this  manual  to  the  public  is  due  to 
the  encouragement  of  our  highly  esteemed  teacher  and 
chef^  Geheimrath  Professor  Gerhardt.  We  have  endeav- 
ored to  supply  a  want  by  giving  in  an  epitomized  form, 
the  different  methods  of  examination,  as  well  as  a  con- 
venient collection  of  those  data  and  figures  which  should 
always  be  familiar  to  the  physician  and  student.  These 
data,  on  account  of  their  number  and  variety,  cannot  be 
remembered  with  the  necessary  exactness,  and,  on  the 
other  hand,  are  so  scattered  throughout  numberless  text- 
books and  monographs,  that  it  would  be  troublesome  and 
time-wasting  to  search  for  them.  In  selecting  and  ar- 
ranging this  material,  we  have  been  led  by  the  experience 
gained  in  holding  courses,  and  we  have  also  endeavored 
to  consider  the  practical  needs  of  the  student  and  physi- 
cian by  noting  only  what  is  reliable,  and  omitting  every 
thing  self-evident  and  of  secondary  importance. 

THE  AUTHORS. 

Würzburg  and  Berlin,  April,  1886, 


PREFACE  TO  THE  THIRD  EDITION. 


In  preparing  the  third  edition  of  this  manual,  I  have 
endeavored  to  do  justice  to  all  the  wishes  expressed  by  the 
different  critics,  as  well  as  to  consider  any  wants  which 
have  become  apparent  since  the  last  edition.  Conse- 
quently, a  number  of  improvements  and  additions  have 
been  made,  and  among  them  it  seemed  necessary  to  add 
some  new  illustrations,  especially  to  the  chapters  on 
blood  and  urine.  The  illustrations  of  the  leucocytes  are 
from  preparations  of  Professor  Ehrlich,  and  those  of  the 
urinary  sediment  are,  in  part,  taken  from  the  physico- 
chemical  atlas  of  Funke.  The  tables  in  the  last  chapter 
are  intended  to  make  the  questions  of  diet  and  assimila- 
tion of  practical  use  in  the  sick-room.  In  conclusion,  I 
should  like  to  thank  all  those  gentlemen  who  have  so 
kindly  assisted  us  by  their  suggestions. 

Berlin,  October,  1886. 


VI 


TRANSLATOR'S  PREFACE. 


The  favor  with  which  this  book  has  been  received  in 
Germany,  and  its  eminently  practical  and  concise  man- 
ner of  dealing  with  the  different  important  points  in  diag- 
nosis, seem  to  justify  its  translation  into  English.  It  has 
been  brought  down  to  the  latest  acquisitions  of  science, 
thus  representing  the  most  advanced  views.  For  the 
sake  of  clearness,  the  figures  relating  to  weight,  measure, 
length,  etc.,  as  well  as  the  dose  table  at  the  end  of  the 
book,  have  been  modified  to  conform  to  the  system  used 
in  America  and  England.  Translations  from  the  original 
into  French  and  Russian  are  now  in  press. 

The  translator  takes  great  pleasure  in  thanking  in  this 

place  his  friend  Dr.  Robert  T.  Wilson,  for  kind  services 

and  valuable  suggestions  rendered  in  the  proof-reading 

and  correction. 

W.  B.  C. 

loio  North  Charles  St.,  Baltimore, 
September,  1887. 


vu 


CONTENTS. 


PAGE 

Preface  to  First  Edition v 

Preface  to  Third  Edition vi 

Translator's  Preface vii 

Chap.  I. — The  Blood i 

Chap.  II. — The  Temperature 8 

Measles     .         .         . .10 

Scarlet-Fever    .         .         .         .         ,         .         .         .         .10 

Small-Pox  .         .         .         .         .         .         .         .       '  .       II 

Varioloid  .         .         .         .         .         .         .    "     .         .11 

Chicken-Pox      .........       12 

Typhoid  Fever  ........       12 

Typhus  Fever  .........       13 

Recurrent  Fever        ........       13 

Malaria     ..........       14 

Erysipelas         .  .         .         .         .         .         .         .         .15 

Pneumonia  Crouposa          .......       15 

Chap.  III. — Organs  of  Respiration 16 

Topography  of  the  Chest  .......       16 

Spirometry         .........       20 

Percussion  of  the  Thorax  .         .         .         .         .         .         .21 

The  Normal  Boundaries  of  the  Lung     ....       21 

Topography  of  the  Different  Lobes  of  the  Lung     .         .       22 

Auscultation 27 

The  Breathing  Sound    .         .         .         .         .         .         .27 

Rales     . 28 

Auscultation  of  the  Voice       .         .         .         ...       29 

Chap.  IV.— The  Sputum       .        .        .        .        .        .        .32 

Morphological  Constituents 34 

Chap.  V. — Laryngoscopy 37 

Voice         ..........       37 

The  Muscles  of  the  Larynx        ......       38 

ix 


X                                             CONTENTS, 

PAGE 

Nerves  of  the  Larynx 38 

Paralysis  of  the  Vocal  Cords      .... 

39 

Chap.  VI. — Circulatory  System          .        .        . 

41 

Inspection  and  Palpation            .... 

41 

Percussion  of  the  Heart     .... 

43 

Auscultation  of  the  Heart 

45 

The  Heart  Murmurs          .... 

46 

Auscultation  of  the  Blood-Vessels 

48 

Chap.  VIL— The  Pulse         .... 

50 

Chap.  VIII. — Digestive  and  Abdominal  Organ 

S 

55 

The  Teeth         ...... 

55 

The  Saliva         ...... 

56 

CEsophagus        .         

56 

Stomach    ....... 

57 

Examination  of  the  Stomach's  Contents 

58 

Liver         ....... 

60 

The  Spleen        ...... 

61 

Abdomen            ...... 

62 

The  Faeces         ...... 

63 

Chap.  IX. — The  Urine-Producing  System 

.       67 

The  Genito-Urinary  Organs 

67 

The  Urine 

67 

Normal  Constituents  of  the  Urine 

70 

Inorganic  Constituents  of  the  Urine 

.       74 

Pathological  Constituents  of  the  Urine 

77 

Organic  Sediments          .... 

89 

Chap.  X. — Transudations  and  Exudations 

91 

Chap.  XI. — Parasites   ..... 

96 

I.    ANIMAL  parasites  : 

Cestodes — Tape-Worms 

.       96 

Nematodes — Round-Worms 

•       98 

Trematodes — Flat-Worms 

.     100 

Arthropodes        ..... 

.     100 

.       lOI 

II.    VEGETABLE   PARASITES  : 

Hyphomycetes    ..... 

.       lOI 

Yeast  Fungi 

.     102 

102 

CONTENTS. 

XI 

PAGE 

Chap.  XI. — The  Nervous  System 

io8 

Testing  the  Sensibility       . 

1 08 

Testing  the  Motility 

III 

Motor  Symptoms  of  Irritation         .          .          .         .         . 

112 

Diagnosis  by  Means  of  Electricity     .... 

1 1.3 

Reflexes    ......... 

121 

The  Most  Important  Clinical  Points  in  the  Anatomy  ol 

the  Nervous  System    ...... 

124 

Brain  and  Spinal  Cord   ...... 

124 

Cranial  Nerves       ....... 

127 

Spinal  Nerves         ...'.•. 

129 

Chap.    XIII. — Analysis    of    the    Pathological    Concre 

MENTS          

132 

Urinary  Concrements         ...... 

132 

Concrements  of  the  Intestine     ..... 

134 

Salivary  Calculi          .....•• 

•     134 

Gall  Stones        ......•• 

.     134 

Chap.  XIV. — Metabolism  and  Nutrition 

.     136 

Table  of  the  Weights  of  the  Human  Body 

•     143 

Dose  Table      .....•••• 

.     144 

Index       .         .         .         .         . 

.     163 

CLINICAL   DIAGNOSIS. 


CHAPTER  I. 
THE  BLOOD. 

The  whole  quantity  of  blood  in  the  body  of  an  adult  is 
equal  to  about  -JL.  of  the  weight  of  the  body — that  is,  on 
an  average,  5  kilograms  [10  Ibs.].^ 

The  specific  gravity  varies  in  health  between  1045  and 

1075- 

The  reaction  of  the  blood  is  alkaline. 

The  amount  of  hceinoglobin'^  in  the  blood  is  about  14.57 
grams  [4  drachms]  in  men,  and  13.27  grams  [3 J 
drachms]  in  women,  in  100  com.  [3  ounces]  of  blood. 
On  heating,  the  haemoglobin  is  resolved  into  brown 
haematin  and  albumen. 

If  some  blood  {e.  g. ,  that  obtained  from  a  blood  stain  on  wood  or 
linen),  be  heated  to  the  boiling  point  with  glacial  acetic  acid  and  a 
trace  of  common  salt,  and  then  slowly  evaporated,  there  are  formed 
brownish-yellow  rhombic  crystals  of  the  muriate  of  h(zmatin,  which 
is  the  same  thing  as  h(zmin  or  Teichmann's  crystals.  The  prepara- 
tion should  then  be  moistened  with  a  little  glycerine,  and  examined 
with  a  high  power  under  the  microscope. 

The  red  blood  corpuscles  measure  in  healthy  individuals 

'  That  part  enclosed  in  [  ]  is  by  the  translator. 
"^  The  amount  of  hsemoglobin  is  determined  by  the  quantitative 
spectral  analysis  or  by  means  of  a  hsemochromometer. 

Z 


2  CLINICAL   DIAGNOSIS. 

from  6.7  yu  to  9.3  ///  The  average  size  is  7.8  /f  (Gram). 
Giant  blood  co7-puscles  are  found  principally  in  the  blood 
of  the  anaemic,  and  especially  in  those  suffering  from 
progressive  pernicious  anaemia.  The  dwarf  blood  cor 
puscles  measure  from  2.2  to  6  /^,  and  are  like  the  normal 
ones,  only  slightly  more  biconcave.  These  are  also 
found  frequently  in  ansemia. 

By  Foikilocytes  are  meant  those  red  corpuscles  of 
irregular  form  (pear-,  club-,  or  biscuit-shaped)  which 
are  seen  in  all  ansemic  conditions.  Microcytes  are  small 
spherical  bodies,   generally  very  rich  in  hemoglobin,  and 

Fig.  1. 
>.  ucleated 
red  blood  corpuscles.         Poikilocytes. 

Dwarf 

blood  corpuscles. 


A  normal 
red  blood 
corpuscle. 


©*^  r^    l\     --^                       ^  Giant 
^    l^^~y^  -  blood  corpuscles. 


Microcytes. 

are  found  in  many  cases  of  burning  and  poisoning.  Still 
we  must  very  often  consider  them  as  artificial  products. 
It  is  uncertain  whether  red  corpuscles  with  crenated 
edges  (thorn-apple-shaped  corpuscles),  appear  in  normal 
blood  or  not.  When  seen,  they  are  generally  considered 
artificial  products  caused  by  evaporation.  Notwith- 
standing this,  they  are  observed  to  form  more  quickly 
and  abundantly  in  many  cachectic  conditions  than  in 
normal  blood. 


^  u  =  the  one-thousandth  part  of  a  millimetre,  and  is  known  as  a 

micro-millimetre  or  micron,  and  equals  about  ^-^(Jq  of  an  inch. 


THE  BLOOD.  3 

Nucleated  red  blood  corpuscles  are  seen  in  all  severe 
'  cases  of  anaemia  but  they  can  only  be  recognized  in 
stained  preparations.^  Very  large  nucleated  blood 
corpuscles  (megalocytes)  are  seen  m  progressive  per- 
nicious anaemia. 

Blood-plaques  (Bizzozero  ^)  =  Hcematoblasts  (Hayem  ^) 
are  colorless  flat  round  discs  about  one  half  the  diameter 
of  a  red  blood  corpuscle.  They  change  their  shapes 
very  quickly  when  outside  of  the  blood-vessel.  The 
elei}ienta7'y  graiiular  masses  are  small,  often  angular, 
colorless  granules  with  a  diameter  of  1-2//.  They  consist 
in  part  of  fat,  and  are  probably  for  the  most  part  disin- 
tegrated products  of  the  blood-plaques. 

Fig.  2.         Fig.  3.  Fig.  4.  Fig.  5.  Fig.  6.  Fig.  7. 


Lymphocytes.        Large  mononuclear  Polynuclear  Polynuclear      Eosinophile 

Small  size.  Large  size.  cell.  cell.  cell.  cell. 

The  white  blood  corpuscles  (Leucocytes)  are  divided 
according  to  Ehrlich  into  :  (i)  Lymphocytes.,  which  are 
about  the  size  of  a  red  blood  corpuscle  or  somewhat 
larger,  with  a  large  round  nucleus,  and  a  very  small, 
often  scarcely  visible,  protoplasm.  We  distinguish  two 
forms,  a  smaller  and  a  larger,  which  latter  is  only  the 
former  in  a  more  progressive  stage  of  development.  The 
lymphocytes  have  their  origin  in  the  lymphatic  glands. 
(2)  Large  mononuclear  forms.^  with  large  round  or  oval 
nucleus  and  broad  protoplasmic  body.  These  are  the 
earlier  stages  of  development  of  the  third.  (3)  The 
large  polynuclear  forni,  containing  a  nucleus  very  much 
divided  and  lobulated,  and  which  may  be  deeply  stained 

1  Fortschritte  der  Medicin,  1884. 

"  Bizzozero  :    Virchows  Archiv.,  Bd.  xc. 

■^Hayem  :   Archive  de  Physiologie,  1878-79. 


4  CLIXICAL   DIAGNOSIS. 

with  aniline  colors.  They  form  by  far  the  greatest 
number  of  the  leucocytes,  and  are  found  almost  exclu- 
sively in  pus.  Ehrlich  designates  as  eosinophile  cells  those 
leucocytes  in  whose  protoplasm  a  quantity  of  coarse, 
fatty,  shining  granules  are  seen,  which  are  colored  an 
intense  red  on  staining  a  preparation  of  dried  blood  with 
a  one-per-cent.  watery  solution  of  eosin.  These  cells 
have  their  origin  in  the  marrow  of  bones,  and  are  present 
in  normal  blood  in  small  quantities  only.  In  myeloge- 
netic  leucaemia  they  are  seen  in  large  numbers.  In 
lymphatic  leucaemia  it  is  principally  the  small  lympho- 
cytes which  are  increased  in  number 

In  order  to  examine  the  blood,  it  is  generally  sufficient  to  cleanse 
and  dr)^  the  finger,  and,  with  a  needle  or  lancet,  to  make  a  quick  and 
deep  puncture  in  the  tip.  The  drop  of  blood  should  then  escape 
without  squeezing  the  finger,  and  be  dropped  on  a  clean  cover-glass, 
which  is,  in  turn,  dropped  on  the  slide  in  such  a  way  that  the  blood 
is  spread  out  in  a  thin  film.  In  order  to  see  the  blood-plaques,  a 
drop  of  a  one-per-cent.  osmic-acid  solution  is  applied  to  the  finger, 
and  the  puncture  is  made  through  this  drop.  Instead  of  the  osmic 
acid,  which  is  simply  a  consers'^ative  fluid,  a  thin  watery  solution  of 
methyl  violet  with  0.6  ^c  of  common  salt  may  be  used,  which  colors 
the  blood-plaques  and  the  nuclei  of  the  nucleated  red  blood- 
corpuscles.  In  finer  examinations  of  the  blood,  it  is  better  to  color 
a  dried  preparation  {znd.  Chap.  xi.  for  preparation)  with  the  follow- 
ing solution  : 

5      Haematoxylin,  2  grams  [30  grains]. 
Alcohol, 
Glycerine, 

Distilled  water,  ää  100  grams  [3  ounces]. 
Glacial  acetic  acid,  10  grams  \2\  drachms]. 
Alum  in  excess. 

This  mixture  should  stand  3  weeks  in  the  light,  and  a  few  granules 
of  eosin  should  be  added  to  it.  The  dry  preparations  remain  from 
6-12  hours  in  the  staining  fluid,  and  then  are  to  be  washed  off  with 
water  and  examined.  The  nuclei  of  the  nucleated  red  blood- 
corpuscles  will  be  found  to  be  stained  intensely  black.     (Ehrlich.) 


THE   BLOOD.  5 

The  number  of  red  blood  corpuscles  is,  on  an  average, 
in  men,  in  the  normal  condition,  5  million  ;  in  women, 
4|-  million,  to  a  cubic  millimetre  [a  millimetre  equals  -^-^ 
of  an  inch]. 

The  number  of  white  blood  corpuscles  varies  between 
5,000-10,000,  and  is  temporarily  increased  after  a  hearty 
meal.  The  number  of  blood-plaques  is  about  200,000  to 
the  cubic  millimetre. 

The  proportion  between  white  and  red  blood  corpuscles 
is,  in  healthy  individuals,  1-500  to  1-1,000.  A  proportion 
which  is  more  than  i  to  400  must  be  considered  as  a 
pathological  increase  in  the  number  of  Avhite  corpuscles. 

Welker  and  Moleschott  considered  the  proportion  of  white  to  red 
corpuscles  to  be  1:330  and  1.357.  Duperie  found  5.500,000,  red  to 
5,000  white,  or  i:iioo  ;  Malassez,  1:1200  ;  Hayem,  Bouchut,  Du- 
brisay  found,  on  an  average,  1:500-1,000  ;  Ilalla,  1:422-811.  Laache 
and  Otto  found,  on  an  average,  for  men  4.97  and  4.99  million,  and 
for  women  4.43  and  4.58  million  red  blood  corpuscles. 

In  order  to  count  the  corpuscles,  a  deep  puncture  is  made  into  the 
finger-tip,  and  the  escaping  drop  is  sucked  up  into  the  me'langeur 
until  it  reaches  the  mark  T.  The  point  of  the  instrument  is  then 
wiped  off,  and  the  dihitüig  fluid  \%  sucked  up  to  the  mark  loi.  This 
mixture  of  blood  and  diluting  fluid  ^  is  well  shaken  and  introduced 
into  the  counting  chamber,  and  covered  by  the  cover-glass,  which 
should  be  lightly  pressed  on,  and  then  the  corpuscles  are  counted  in 
each  square,  which  is  etched  on  the  cover-glass.  If  a  thousand  cor- 
puscles have  been  counted  in  one  square,  the  amount  of  corpuscles 
in  a  cubic  millimetre  can  be  calculated,  since  the  dilution  of  the  blood 
(1:100)  and  the  depth  of  the  chamber  are  known.  By  using  the 
chamber  of  Thoma-Zeiss  (depth  ^  mm.,  i  square  =  ^^  cubic 
millimetre),    the  average   number  of   corpuscles  in   a  small  square 


^  This  fluid  may  be  either  a  3  ,^  solution  of  common  salt,  or  a  5  ^ 
solution  of  Glauber's  salt,  or  Hayem's  solution,  which  is  corrosive 
sublimate,  0.5  grams  [7  grains],  Glauber's  salt,  5.0  [i|-  drachms], 
common  salt,  2,0  [i  drachm],  distilled  water  200.0  grams  [6  ounces]. 


6  CLINICAL   DIAGNOSIS. 

is  multiplied  by  400,000 — that  is,  the  whole  number  of  corpuscles 
is  to  be  divided  by  the  number  of  squares  which  have  been  counted. 
It  is  more  convenient  to  count  the  four  small  squares  in  one  col- 
umn and  calculate  the  average  result  of  a  large  number  of  counts. 
This  number,  which  is  the  number  of  blood  corpuscles  in  any  four 
squares,  is  then  multiplied  by  100,000.  In  using  the  chamber  of 
Malassez  or  Hayem,  which  has  a  depth  of  i  mm.,  the  average  num- 
ber which  is  in  a  large  rectangle  (=20  small  squares)  is  to  be  multi- 
plied by  10,000.  If  the  blood  dilution  is  1:200  instead  of  1: 100,  i,  e. 
(up  to  mark  0.5  of  the  melangeur),  the  result  should  be  multiplied 
by  2. 

Leiccocytosis,  that  is,  an  increase  of  the  leucocytes  in  proportion  to 
the  red  corpuscle,  is  observed  in  numerous  acute  diseases  (typhus 
abdominalis,  erysipelas,  etc.),  also  in  cachectic  conditions  (cancer). 
This  increase  of  leucocytes  is  often  very  great,  and  may  even  reach 
as  high  as  i  to  60  red  corpuscles. 

In  Leuccemia,  the  amount  of  red  corpuscles  as  well  as  of  haemoglobin 
is  generally  considerably  decreased,  so  that  the  number  of  leucocytes 
is  very  considerably  increased,  and  almost  equals  that  of  the  red 
corpuscles  ;  indeed  it  may  equal  or  exceed  it.  In  the  first  stages  of 
the  disease,  when  the  increase  of  the  white  corpuscles  is  often  less 
than  in  severe  leticocytosis,  the  diagnosis  of  ieuccemia  can  be  certain 
only  when,  in  its  further  course,  a  rapid  increase  of  leucocytes  makes 
it  very  evident  ;  or  when  the  proportion  of  white  to  red  exceeds 
1:50.  In  myelogenetic  leucaemia,  there  are  numerous  eosinophile 
leucocytes,  and  also  nucleated  red  blood  corpuscles  to  be  seen. 
Ly7Jiphatic  leucaemia  is  characterized  by  an  increase  of  lymphocytes. 

\vl  pseudoleuc&mia  there  is  a  slight  decrease  in  the  number  of  red 
corpuscles,  and  in  the  amount  of  haemoglobin,  and  no  increase  of 
the  leucocytes. 

In  the  first  few  days  after  heavy  loss  of  blood,  the  amount  of  red 
corpuscles  as  well  as  of  the  haemoglobin  sinks  markedly  to  over  50  ^ 
of  the  normal,  whereas  the  number  of  leucocytes  increases.  In  the 
period  of  convalescence,  the  amount  of  red  corpuscles  increases  more 
quickly  than  that  of  the  haemoglobin.  In  the  secondary  ajiczmicz, 
after  typhus  abdominalis,  tuberculosis,  malaria,  lead  poisoning, 
ankylostomiasis,  nephritis,  cancer,  etc.,  the  number  of  red  cor- 
puscles as  well  as  the  amount  of  haemoglobin  is  diminished,  and  the 
amount  of  white  blood  corpuscles  increased  (leucocytosis). 


THE  BLOOD. 


7 


In  chlorosis  the  amount  of  hemoglobin  is  very  greatly  decreased, 
whereas  the  number  of  red  corpuscles  is  often  very'  little  or  not  at  all 
increased.  These  are  therefore  very  pale.  The  amount  of  white 
corpuscles  is  normal. 

In  progressive  perniciotis  ancemia,  the  number  of  red  corpuscles  is 
enormously  reduced,  often  to  ^  of  the  normal,  whereas  their  size, 
and  above  all  things,  the  amount  of  hcemoglobin  is  increased. 

An  increase  in  the  number  of  red  corpuscles  is  observed  in  thicken- 
ing of  the  blood  in  cholera,  as  well  as  in  many  heart  affections. 

After  long-existing  malaria,  pigi7ient-containing  letccocytes  are  at 
times  seen  in  the  blood. 

Micro-organisms  are  also  observed  in  the  blood — e.  g.,  tubercle 
bacilli  in  miliary  tuberculosis,  bacilli  leprce,  bacilli  anthracis,  and  the 
spirilla  of  reciirrent  fever.  The  latter  can  be  seen  with  medium 
power,  and  are  best  recognized  from  the  fact  that  when  they  come  in 
contact  with  the  red  blood  corpuscles,  they  impart  to  them  a  jerking 
motion  ;  or  they  can  be  recognized  by  coloring  them  as  a  dried  prep- 
aration, with  a  watery  solution  of  gentian  violet,  as  in  the  case  of 
the  bacilli  anthracis. 


CHAPTER  II. 

TEMPERATURE. 

The  temperature  of  the  body  is  generally  taken  either 
in  the  axillary  space  or  in  the  rectum  [and  under  the 
tongue].  In  the  rectum  it  is  about  0.5°-:°  higher  than 
in  the  axilla. 

The  temperature  of  the  healthy  individual  measures  ^  in 
the  axilla  between36.2°  C.  [97.1°  F.]  and  37.5°  C.  [99.5°  F.]. 
The  highest  temperature  is  late  in  the  afternoon,  and  the 
lowest,  very  early  in  the  morning.  An  elevation  of  tem- 
perature can  temporarily  occur  in  consequence  of  bodily 
exertion,  taking  food,  hot-baths,  etc.  A  continuous  ele- 
vation of  temperature  occurs  /;/  fever.  According  to 
Wunderlich  we  have  : 

The  temperature  of  collapse,  36°  C.  [96.8°  F.]. 

Sub-febrile  temperature  37.5°-38°  C.  [99.5°  F.-ioo.4° 
F.]. 

Slight  fever  38°-38.5°  C.  [ioo.4°-ioi.3°  F.]. 

Moderate  fever  39°  C.  [102.2°  F.]  morning  ;  39.5° 
[103.1°  F.]  evening. 

Considerable  fever  39.5°  C.  [103.1°  F.]  morning  ;  40.5° 
C.  [104.9°  F.]  evening. 

High  fever  over  39.5°C.  [103.1°  F.]  morning;  over 
40.5°  C.  [104.9°  F-]  evening. 

'  In  order  to  convert  from  one  scale  to  the  other,  the  following 
formula  may  be  used  : 

N°  C  =  |nO  R  =  f  n«  +  32°  F. 


TEMPERA  TÜRE.  9 

Hyperpyrexia,  or  fever  over  41.5°  C.  [106.7°]. 

Also  in  fever  there  is  usually  a  morning  remission  and 
an  evening  exacerbation.  Exceptionally,  especially  in 
phthisis,  we  have  the  reverse — typus  inversus.  The 
difference  between  the  highest  and  lowest  tempera- 
ture  decides  its  type  of  the  fever,  thus  : 

Febris  co7itinua  =■  a  daily  difference  of  not  more  than 
1°  C.  [1.8°  F.]. 

Febris  remittens  =  a  daily  difference  of  not  more  than 
1.5°  C.  [2.7°  F.]. 

Febris  intermittens  =  in  the  course  of  the  dav  the  high 
temperature  is  varied  by  a  period  of  no  fever. 

In  the  course  of  a  fever  we  distinguish  : 

I.  Stadium  incrementi  =  a  quick  rise  of  temperature, 
generally  accompanied  by  a  chill  or  a  slowly  rising 
temperature, 

II.  Fastigium  rz:  or  a  stage  of  highest  temperature.  Its 
transition  to  the  next  stage  is  known  as  the  amphibolic 
stage. 

III.  Stadium  decrementi.  The  fever  fall  can  follow 
either  slowly,  in  course  of  several  days,  in  which  case  we 
have  lysis  ;  or  quickly,  the  crisis.  At  the  actual  crisis 
the  temperature  falls  rapidly  (in  one  day)  until  it  goes 
below  normal.  This  fall  is  generally  accompanied 
by  a  profuse  perspiration.  A  high  rise  of  temperature 
often  precedes  the  crisis,  which  is  called  perturbatio 
critica. 

In  acute  infectious  diseases  we  distinguish  the  stage  of 
incubation — that  is,  the  time  between  the  moment  of  con- 
tagion and  the  outbreak  of  the  disease.  Also  in  acute 
exanthematous  diseases  there  is  the  prodromal  stage,  or 
stage  of  the  first  morbid  appearances,  i.  e.,  before  the 
outbreak  of  the  eruption. 


lO 


CLINICAL   DIAGNOSIS. 


Fig.  8. 
Temperature  chart  in  IMorbilli. 


F° 

1058 

104. 


Morbilli— Measles. 

Incubation,  ten  days.     Prodromal    stage,  three  days, 
characterized  by  affections  of  the  mucous  membranes. 

It  begins  with  chill  and  high 

fever ;    and    on   the    second 

or  third  day  there  is  a  slight 

fall  of  temperature.     At  the 

appearance   of   the  eruption 

(on  the  face)  the  temperature 

^°^'^  rises  again,  and  reaches   its 

100.4  highest  point  when  the  erup- 

98.6  tion  is  most  widely  dissemi- 

g58  nated.     This  is  the  stadium 

Prodromes.  Eruption.   Defervescence.  floritionis,  and   laStS     threC    tO 

four  days.  The  critical  fall  of  temperature  occurs  on 
the  sixth  or  seventh  day  of  the  disease,  after  which  des- 
quamation begins. 

Scarlatina — Scarlet-Fever. 

Incubation,  four  to  seven  days.  Prodromal  stage,  one 
to  two  days.  It  is  characterized  by  angina.  It  begins 
with  a  chill  and  quick  rise 
of  temperature.  At  the  end 
of  the  first  or  second  day 
there  is  an  outbreak  of  the  c° 
eruption  (on  the  breast),  and  41,0 
as  it  spreads  the  tempera-  ^^^ 
ture    rises.       Defervescence 


Fig.  9. 

Temperature  chart  in 

Scarlatina. 


begins   on  fourth  to  seventh 


390 


day  of  the  disease,  and  comes  ^^■° 
to  an  end  slowly,  with  the  37-0 
paling  of  the  eruption  in  36.0 
three  to  six  days  later.     Desquamation  then  follows. 


TEMPERA  TÜRE. 


II 


Fig.  lo.     Temperature  chart  in  Variola. 


Variola — Small-pox. 

Incubation,  nine  days  (nine  to  sixteen  days),  at  the 
end  of  which  time  there  is  general  disturbance  of  func- 
tions. The  prodromal  stage  (two  to  five  days)  begins 
with  a  chill, 
with  sudden 
rise  of  tem-  ^° 
perature,  and  41.0 
often  on  the 
second  or 
third  day  the 
first  signs  of 
the  eruption 
are   observed,    s'^o 


laaBBOQiiBEElEDISEOBIE 

niiSiiliiiMSgl 


sasi 


lliiiiiiiiiiii 

iHiiiii 

IBBSBSgsS 
IBBBBSBB 


105.8 

104. 

102.2 

100.4 

98.6 
96.8 


Prodromes.   Eruption.    Fever  of  suppuration.   Desquamation. 

With  the  be- 
ginning of  the  pustulation  there  is  a  quick  fall  of  tem- 
perature. Then  comes  a  second  and  in  the  beginning 
a  slight  febrile  movement,  which  reaches  its  climax  on 
about  the  ninth  day  (fever  of  suppuration),  preserves  a 
remittent  type  for  some  time,  and  after  a  varying  length 
ends  in  lysis  (period  of  desquamation).  About  the  six- 
teenth day  the  stadium  decrustationis  begins. 

Variolois — Varioloid. 


Fig.  II.     Temperature  chart  in  Variolois. 


The  incubation 
and  prodromal  stag- 
es are  the  same  as 
in  variola  vera,  only 
much  lighter.  The 
second  period  of 
fever  (fever  of  sup- 
6  puration)  is  want- 
96.8  ing.     The  period  of 


12 


CLIN  IC  A  L   DIA  GXOSIS. 


desquamation  often  begins  as  early  as  the  ninth  or  tenth 
day,  and  is  generally  accompanied  by  slight  rise  of 
temperature. 

Varicella — Chicken-pox, 

The  prodromes  are  generally  wanting.      The  eruption 
o      'S,     4     ^     d"    S     2     of   the    vesicles    begins    with 

slight  fever.    The  vesicles  dry 
up  after  three  or  four  days. 

Typhus  Abdominalis — 
Typhoid  Fever. 

Incubation,  seven  to  twenty- 
one  days.  The  prodromal 
stage  lasts  several  days  to  a 
week,  and  is  accompanied  by 
general  disturbances.  In  the 
first  week  of  the  disease  the 
temperature  rises  by  degrees, 
accompanied  by  slight  chills, 
and  reaches,  on  the  fourth  or 
seventh  day,  its  highest  point. 
This  continues  as  a  febris  con- 
tinua  until  the  third  week  in 
the  milder  forms,  and  until 
the  fifth  w^eek  in  the  more 
severe  forms.  Then  the  morn- 
ing temperature  begins  gradu- 
ally to  fall,  while  the  evening 
temperature  still  remains  high, 
until  gradually  lysis  results, 
which  in  mild  cases  is  in  the 
Ü     «"      5      dv    od     t:.     >o     fourth    week.     There    is    also 


TEMPERA  TÜRE. 


13 


tumefaction  of  the  spleen  in  the  second  half  of  the  first 
week  of  the  disease.  Roseola  occurs  on  the  sixth  to 
ninth  day  of  the  disease. 

Typhus  Exanthematicus — Typhus  Fever. 

Incubation  varies  from  a  few  days  to  three  weeks. 
The  prodromal  stage  is  not  marked.  The  disease  begins 
with  a  chill  and  rapid  rise  of  temperature,  and  then  it 
remains  febris  continua  until  the  thirteenth  to  the  seven- 


Fig.  13.     Temperature  chart  in  Typhus  exanthematicus. 


C° 
41.0 
40.0 

39,0 
38.0 
37-0 
36.0 


lüiBiigiiiiiiiii 


105.8 

104. 

102.2 

100.4 

98.6 
96.8 


Eruption. 


teenth  day.  There  are  often  remissions  at  the  end  of 
the  first  week.  There  is  then  a  critical  fall  of  tempera- 
ture, at  times  with  transitory  perturbatio  critica.  The 
eruption  appears  on  the  third  to  the  sixth  day  after  an 
inflammation  of  the  mucous  tracts. 

Febris  Recurrens — Recurrent  Fever. 

Incubation  five  to  seven  days.  The  prodromal  stage 
is  not  clearly  marked.  The  fever  begins  with  violent 
chill  and  a  (high)  sudden  rise  of  temperature,  which  con- 
tinues as  in  febris  continua  until  the  fifth  or  seventh  day, 
and  then  critically  falls.  After  a  period  of  apyrexia,  last- 
ing about  a  week,  there  is  again  an  attack  of  fever  as  at 


14 


CLIN  I  CA  L  DIA  GNO  SIS. 


first,  but  not  lasting  so  long.  Often,  after  a  period  of 
seven  days,  there  is  a  third  attack,  lasting  one  to  two 
days. 

Fig.  14.     Temperature  chart  in  Febris  recurrens. 


41.0 
40.0 

39-0 
38.0 

37-0 
36.0 


piiiiSaiHEiiiRiSl 

PüiaiinBÜEBBläli 

iJÜEgiiSSSaiigHSSiBi 

wiSEaBaHiiaaBBiBl 

ISEiglSBSeSSlBBilBlSi 

BBSBSigSSBIBEiBBBBi 

F° 

105.8 

104. 

102.2 

100.4 
98.6 
96.8 


Malaria — Febris  Intermittens. 

Incubation    seven    to    tv>^enty-one    days.       Prodromal 
stage  is  not  marked.     There  is  a  chill,  and  the  tempera- 
ture rises  to  very  great  height,  and  then  sinks  after  a  few 
hours  to  or  below  the  normal.     There  is  also  strong  per- 
Fig_  J,  spiration.      According    as 

Temperature  chart  in   Febris  intermittens,    the      fe\'er      OCCUrS       CVerV 

day,  or  every  second  and 


c° 

41.0 
40.0 
390 
38.0 

37-0 


isnissaBiiissBB^ 

'SSSIBBSgiBlsSSgB 

ä&i!gS5|iiS»S 

[■■■■!■■■  BsEBBimBaiai^^i 

■■■■■[■■■—■■IW^— i^Bl 

B«WII«IMB«^Bw»BlgBBgg— I 
isisäSiässSsssIsSSBS 


36.0 

Febris  quotid ;       tertiana ;        quartana. 


F° 

105.8   third  day,  it  is  called  quo- 
jQ^      tidian,  tertian,  and  quar- 


100.4 


tan      intermittent     fever. 

Febris  intermittens  dupli- 

cata  is  that  type  in  which 
■^  two  attacks  occur  in  quick 
•8    succession  in  the  course  of 

the  same  day.  Febris  inter- 
mittens anteponens  and  post-ponens  is  that  type  in  which 
the  new  attack  of  fever  does  not  generally  occur  at  the 
same  hour  of  the  day  as  the  preceding  attack,  but  sooner 
or  later. 


TEMPERA  TÜRE. 


15 


Fig.  16. 

Temperature  chart  in 

Erysipelas. 


■I  ^'  •  W<  ^.Bi  .WJB  >"<WI  ^111  ^^  Db3 

HM  löViS  ^jiH  K^gaSi  n/fii^H  ^B 


105.8 

104. 
102.2 

100.4 


Erysipelas. 

Incubation   one   to   eight    days.      It    generally    begins 
with  a  chill  and  high  temper- 
ature.  On  the  first  or  second 
day  an  inflammation  of  the    ^o 

skin  is  observed.     The  tem- 

41.0 

perature  continues    high    as 

long  as   the  morbid  process  "^"'^ 

spreads,  and  quickly  falls  as  ^^'° 

soon  as  the  erysipelas  ceases  3^-°     _ 

!n  BS  B9  SB  S"  ^"^ ''^  "^ 

spreadmg.  With  the  spas-  37-0  ipBBBBSsBBBiüÜ  9^-^ 
modic  spread  of  the  erup-  360  EJiaSaBBBMSBBil  ^gg 
tion  there  is  often  found  a  remittent  or  intermittent  fever. 

Pneumonia  Crouposa. 

It  begins  with  a  chill  and  sudden  rise  of  temperature. 
There  is  a  continued  fever  during  the  spread  of  the 
peneumonic  infiltration.  On  the  fifth  to  the  seventh 
day,  and  at  times  later,  the  crisis  occurs^  generally  very 

Fig.  17.  Fig.  iS. 

Temperature  charts  in  Pneumonia  crouposa. 


41.0 


40  o 


i^Tji 


F° 
105.8 
104. 
102.2 

100.4 

q8.6 


96. 


suddenly,  with  strong  perspiration,  and,  at  the  same  time, 
a  decrease  in  the  frequency  of  the  pulse  and  respiration. 
There  is  often  a  pseudo-crisis  (v.  Fig.  18)  one  or  two 
days  before  the  real  crisis,  but  here  the  pulse  and  respira- 
tion remain  high. 


CHAPTER  IIL 

ORGANS  OF  RESPIRATION 

Topography  of  the  Chest. 

The  vertebral  colunui  has  a  normal  curvature  at  the 
cervical,  dorsal,  lumbar,  and  sacral  regions.  A  patho- 
logical curvature  of  the  vertebral  column  convexly  back- 
ward is  called  cyphosis.  The  same  deformity,  not  curved 
but  angular  in  character,  is  called  gibbus.  A  curvature 
forward  is  called  lordosis,  and  a  lateral  curvature  scoliosis. 
A  deforming  curvature  both  laterally  and  backward  is 
called  cypho-scoliosis. 

The  sternum  in  the  adult  is  about  16-20  cm.  [6—8 
inches]  long.  The  angular  prominence  between  the 
manubrium  and  body  is  called  the  angulus  Ludovici.  A 
bending  inward  of  the  xiphoid  process,  and  of  the  lower 
part  of  the  body,  is  called  funnel  breast.  This  latter 
shape  of  the  thorax  is  acquired^  and  is  seen  in  some 
occupations,  e.  g.,  in  cobblers  who  press  their  instru- 
ments against  the  breast  (cobbler's  breast).  "When  the 
costal  cartilages  in  rachitis  are  pressed  in  by  lateral  com- 
pression, and  the  sternum  has  a  keel  shape,  it  is  called 
pectus  carinatum  or  chicken  breast. 

The  clavicle  has  a  supra-  and  infra-clavicular  groove 
in  it.  The  external  part  of  the  latter  is  called  Mohren- 
heim's  groove. 

The  scapula  covers  the  second  to  seventh  or  third  to 
eighth  rib,  and  is  provided  with  a  fossa  supraspinata  and 

16 


ORGANS  OF  RESPIRATION.  1/ 

a  fossa  infraspinata.  Between  the  inner  border  of  each 
scapula  is  the  inter-scapular  space. 

In  order  to  determine  the  height  of  the  thorax  in  front, 
we  must  follaw  the  ribs  by  beginning  to  count  at  the 
second  ;  and  behind  the  landmarks  are  the  spinous  pro- 
cesses, beginning  with  the  seventh  cervical,  the  vertebra 
prominens. 

The  Hari'ison  fui'row  has  a  horizontal  direction  at  the 
level  of  the  xiphoid  process,  and  corresponding  to  the 
normal  attachment  of  the  diaphragm.  The  region  be- 
low this  furrow  to  the  angle  of  the  ribs  is  called  the 
hypochondrium. 

In  order  to  determine  the  breadth  of  the  thorax^  we 
make  use  of  the  following  perpendicular  lines  : 

(i)  The  median  line. 

(2)  The  parasternal  line,  drawn  half-way  between  the 
border  of  the  sternum  and  the  nipple. 

(3)  The  mammary  line,  drawn  through  the  nipple, 
which,  in  healthy  adults,  lies  between  the  fourth  and 
fifth  ribs,  10  cm  [4  inches]  distant  from  the  border  of  the 
sternum. 

(4)  The  anterior,  middle,  and  posterior  axillary  line  ; 
the  former  drawn  through  the  anterior,  the  latter  through 
the  posterior,  boundary  of  the  axilla. 

(5)  The  scapular  line,  drawn  through  the  lower  border 
of  the  scapula. 

The  costo-articularline  is  a  line  drawn  from  the  sterno- 
costal articulation  to  the  tip  of  the  eleventh  rib. 

Size  of  the  Thorax.  The  sterno-vertebral  diameter  of 
the  thorax  measures,  in  healthy  men,  16.5  cm.  [6|- inches] 
above,  and  19.2  cm.  \j\  inches]  below,  and  in  women  it 
is  somewhat  smaller.  The  broad  diameter  of  the  chest  is, 
in  men,  at  the  height  of  the  nipple,  26  cm.  [10  inches]. 


1 8  CLINICAL  DIAGNOSIS. 

The  circumference  of  the  chest  at  the  height  of  the 
nipple  measures,  in  healthy  men,  82.0  cm.  \j,2\  inches], 
after  deep  expiration,  and  90  cm.  [36  inches]  after  deep 
inspiration — that  is  to  say,  the  maximum  excursion  of  the 
thorax  in  respiration  is  8.0  cm  [3  inches].  In  those  who 
are  right-handed,  the  circumference  of  the  right  half  of 
the  chest  is  0.5  to  2.0  cm  [|-  to  i  inch]  larger  than  the 
left.  In  left-handed  persons  the  left  side  is  slightly 
larger. 

Enlargement  of  one  or  both  sides  of  the  chest  is  observed  in 
pneumothorax,  in  effusions  into  the  pleural  sac  (occasionally  in  pneu- 
monia), often  in  mediastinal  tumors,  and  in  emphysema.  In  the 
latter  disease  there  is,  in  severe  cases,  a  barrel-shaped  chest,  while 
all  the  diameters,  but  especially  the  sterno-vertebral  diameter,  are 
enlarged,  so  that  there  results  a  permanent  position  of  inspiration. 
Enlargements,  especially  of  the  lower  opening  of  the  thorax,  occur 
with  tumors  and  effusions  in  the  peritoneal  cavity. 

A  narrow  thorax  may  be  congenital  or  acquired.  A  congenital 
narrowing  of  the  thorax,  in  which  it  is  long,  small,  shallow,  while 
the  intercostal  spaces  are  broad  and  the  sterno-vertebral  diameter  is 
especially  smaller,  is  called  a  paralytic  shape  of  the  thorax,  and  is 
most  frequent  in  phthisis  pulmonum. 

An  acquired  narrowing  of  the  thorax  may  be  caused  by  an  ab- 
soi-ption  of  a  pleuritic  exudation  and  shrinkage  of  the  lungs,  as  in 
phthisis  and  cirrhosis  pulmonum. 

The  number  of  respiratio?is  in  the  healthy  adult  is  from 
l6  to  20,  and  in  new-born  children  44,  a  minute. 

The  normal  relation  between  the  frequency  of  respiration 
and  pulse  is  as  i:3|-  to  4. 

The  inspiratory  enlargement  of  the  thorax  takes  place 
in  the  male,  principally  by  a  deep  descent  of  the  abdo- 
men, and  partly  by  the  raising  of  the  ribs  by  the  scaleni 
and  intercostal  muscles  —  typus  costo-abdominalis.  In 
women,  the  inspiration  is  carried  on  more  by  raising 
the  ribs — typtis  costaUs, 


ORGA.VS   OF  RESPIRATION.  1 9 

The  expiratory  narrowing  of  the  thorax  is,  under  nor- 
mal conditions,  caused  only  by  the  elasticity  of  the 
chest,  without  muscular  assistance. 

Inspiration  and  expiration  are  generally  of  the  same 
duration,  and  follow  each  other  without  the  intervention 
of  a  pause. 

The  lungs  perform  no  active  movement  during  respira- 
tion, but  passively  follow  the  movements  of  the  chest  wall 
and  the  diaphragm.  In  healthy  individuals  at  rest,  infre- 
quent and  superficial  respirations  are  sufficient  to  change 
the  air  in  the  lungs,  but  as  soon  as  the  amount  of  carbon- 
ic acid  gas  becomes  too  great  in  the  lungs,  the  respira- 
tion becomes  more  frequent  and  deeper.  This  is  seen  in 
bodily  exertion  and  fever,  and  also  in  disturbances  of  the 
circulation  in  consequence  of  heart  troubles,  and  in  all 
diseased  conditions  of  the  respiratory  tract  itself.  If  the 
blood  is  overloaded  with  carbonic  acid  gas  to  too  great 
an  extent,  difficulty  of  breathing,  /,  e.,  dyspnoea,  sets  in. 

In  inspiratory  dyspncea,  in  which  long-drawn  inspirations  are  car- 
ried out  with  great  muscular  exertion,  while  the  expirations  follow 
more  easily,  the  accessory  muscles  come  into  play.  The  sterno- 
mostoidei,  scaleni,  levatores  costarum,  serratus  posticus  superior,  ser- 
ratus  anticus  major,  pectoralis  major  and  minor,  levator  scapulae, 
trapezius,  rhomboidei  major  and  minor,  the  extensors  of  the  vertebral 
columns,  the  dilators  of  the  nasal  and  oral  cavities  as  well  as  of  the 
larynx.  This  kind  of  dyspnoea  is  observed  in  narrowing  of  the  air 
passages — e.  g.,  of  the  larynx,  the  trachea,  and  the  bronchi,  as  well 
as  in  many  diseased  conditions  of  the  lungs  where  there  is  a  decrease 
pf  the  respiratory  surface. 

In  severe  inspiratory  dyspnoea,  there  is  an  inspiratory  drawing  in 
in  the  region  of  the  xiphoid  process  and  the  lower  border  of  the 
ribs. 

In  expiratory  dyspnoea,  in  which  the  narrowing  of  the  chest  is  ren- 
dered difficult,  and  the  length  of  the  expiration  is  increased  in  pro- 
portion to  that  of  the  inspiration,  the  abdominal  muscles  and  the 


20  CLINICAL   DIAGNOSIS. 

serratus  posticus  inferior  and  the  quadratus  lumborum  come  into  play 
as  the  accessory  muscles  of  respiration.  Expiratory  dyspnoea  is  ob- 
served in  cases  of  laryngeal  polypus,  more  especially  in  emphysema 
and  bronchial  astJwia. 

The  mixed  form  of  dyspnoea  is  made  up  of  the  inspiratory  and 
expiratory  dyspnoea. 

Changes  in  the  Frequency  of  Breathing. 

Increase  in  respiratory  frequency  takes  place  : 

1.  From  nervous  causes,  in  all  affections  of  the  mind,  and  in 
hysteria. 

2.  From  accumulation  of  carbonic  acid  gas  in  the  blood,  from 
bodily  exertion,  in  fever,  and  in  many  forms  of  heart  disease. 

3.  In  most  diseases  of  the  respiratory  tract,  such  as  pneumonia, 
phthisis,  pleurisy,  emphysema,  accumulation  of  fluid  and  liquid  in 
the  pleural  cavity,  and  finally,  in  all  diseases  of  the  abdomen — e.  g. , 
in  peritonitis,  tumors,  ascites,  which  hinder  the  movements  of  the 
diaphragm. 

The  relation  between  the  frequency  of  the  pulse  and  respiration 
may  thus  be  changed  from  1:4  to  i:i. 

Retarding  of  the  respiration  is  observed  in  stenosis  of  the  upper  air- 
passages,  and  in  cerebral  diseases  (as  in  hemorrhages,  tumors,  etc.). 

The  Cheyne- Stokes  respiratioji  is  a  kind  of  breathing  in  which 
periods  of  complete  cessation  from  breathing  (apncea)  are  varied 
with  periods  of  slowly  rising  respiratory  movements,  which  become 
gradually  deeper,  and  then,  in  turn,  fall.  This  phenomenon  is 
obser.-ed  in  many  severe  cerebral  diseases,  in  heart  disease,  and 
uraemia. 

Spirometry. 

The  total  capacity  of  the  limgs,  i.  e.,  that  quantity  of  air 
which,  after  forced  inspiration,  can  be  expelled  by  forced 
expiration,  is  about  3,000-4,000  ccm.  [200-250  cubic 
inches]  in  a  healthy  man,  or  an  average  of  3,600  ccm. 
[230  cubic  inches]  ;  in  woman,  2,000—3,000  ccm.  [125—200 
cubic  inches],  or  an  average  of  2,500  ccm.  [163  cubic 
inches].  This  capacity  increases  with  the  growth  of 
the  body,   so  that  about  22   ccm.  [i^  cubic  inches]  of 


ORGANS   OF  RESPIRATION-.  21 

expired  air  would  be  equivalent  to  about  i  cm,  [^  of  an 
inch]  in  the  adult.  The  capacity  of  the  lungs  is  not  so 
great  in  children,  in  old  men,  in  all  diseases  of  the 
stomach,  and  when  the  stomach  is  full. 

The  complemental  air  is  that  amount  of  air  which,  after 
quiet  inspiration,  can  be  introduced  by  forced  inspira- 
tion, and  equals  1,500  ccm.  [100  cubic  inches]. 

The  reserve  air  is  that  amount  of  air  which,  after  quiet 
expiration,  can  be  expelled  by  forced  expiration,  equal 
to  about  1,500  ccm.  [100  cubic  inches]. 

The  ordinary  breathing  air  is  that  amount  of  air  which 
is  introduced  and  expelled  in  quiet  respiration,  and  is 
equal  to  about  500  ccm.  [33  cubic  inches]. 

T\\Q  residual  air  YSi  \\\2X  amount  of  air  which  remains 
in  the  lungs  after  the  deepest  exspiration,  and  equals 
about  1,600—2,000  ccm.  [100-125  cubic  inches]. 

Percussion  of  the  Thorax. 

In  percussion,  the  following  qualities  of  sound  are  dis- 
tinguished : 

I.  Clear  and  dull. 
(2.  Full  and  empty.) 

3.  Tympanitic  and  non-tympanitic. 

4.  High  and  deep. 

Besides  these,  we  have  the  metallic  sound  and  cracked- 
pot  sound  (bruit  de  pot  fele). 

In  the  normal  thorax  there  is  a  clear  sound  over  the 
lungs,  and  a  dull  sound  over  the  organs  not  containing 
air. 

The  Normal  Boundaries  of  the  Lung. 

The  upper  boundary  of  the  lungs  (apex)  is,  in  front,  3-4 
cm.  [i-i^  inch]  above  the  upper  border  of  the  clavicle, 


22  CLINICAL   DIAGNOSIS. 

and  behind,  it  is  on  a  level  with   the   spinous   process 
of  the  seventh  cervical  vertebra. 

The  lower  border  of  the  lungs  is,  at  the  right  border  of 
the  sternum,  on  a  level  with  the  sixth  rib  ;  in  the  right 
mammary  line  it  is  at  the  upper  border  of  the  seventh 
rib  ;  in  the  anterior  axillary  line  at  the  lower  border  of 
the  seventh  rib  ;  and  in  the  scapular  line  at  the  ninth  rib  ; 
and  at  the  vertebral  column  at  the  spinous  process  of  the 
eleventh  dorsal  vertebra.  On  the  left  of,  and  near  the 
sternum  is  the  cardiac  dulness.  The  boundary  between 
the  left  lung  and  the  tympanitic  stomach  is  not  easily 
defined. 

Topography  of  the  Different  Lobes  of  the  Lung. 

The  border  between  the  upper  and  lower  lobes  begins  behind,  on 
both  sides,  at  the  level  of  the  second  and  third  dorsal  vertebra,  takes 
its  course  downwards  and  outwards,  and  reaches  its  limit  on  the  left 
side  in  the  mammary  line  at  the  sixth  rib  ;  on  the  right  side  it  divides 
about  6  cm.  \2\  inches]  above  the  angle  of  the  scapula  into  an  upper 
and  lower  branch  which  embrace  the  middle  lobe.  The  upper  one 
takes  a  course  slightly  downwards,  and  reaches  the  anterior  border 
of  the  lung  at  the  height  of  the  fourth  or  fifth  costal  cartilage  ;  the 
lower  one  separating  the  middle  lobe  from  the  lower  lobe,  goes 
straight  down  to  reach  the  lower  border  of  the  lung  at  the  mammary 
line.  On  percussion  behind,  therefore,  we  have,  on  both  sides,  the 
upper  lobe  only  to  the  third  rib,  and  from  there  on  downwards  the 
lower  lobe  ;  in  front,  on  the  left  side,  only  the  upper  lobe,  and  on 
the  right  side  the  upper  and  middle  lobes. 

In  quiet  respiration  the  lung  borders  move  but  little ; 
in  a  supine  position,  the  anterior  lower  border  is  about 
2  cm.  [i  inch]  lower  than  in  an  upright  position  ;  in  lying 
on  the  side,  the  lower  lung-border  of  the  opposite  side 
descends  in  the  axillary  line  3-4  cm.  [i-i|-  inches].  In 
extreme  inspiration  the  respiratory  movement  can  be  very 


ORGANS   OF  RESPIRATION,  23 

considerable,  and  in  forced  inspiration,  while  lying  on  the 
side,  the  displacement  may  be  as  much  as  9  cm.  \j^\ 
inches].  The  respiratory  movement  of  the  lungs  (by 
filling  the  complemental  space)  is  greatest  in  the  axillary 
line. 

In  emphysema  the  lower  border  of  the  lung  is  observed  to  be 
permanently  lower,  and  in  asthmatic  attacks,  temporarily  lower  than 
in  the  normal. 

The  lower  border  of  the  lung  is  higher  than  normal  in  all  contrac- 
tions of  the  lung  and  pleura,  by  pressure  upward  of  the  diaphragm, 
as  well  as  by  collections  of  air,  and  fluids,  and  of  tumors  in  the  ab- 
dominal cavity.  The  upper  border  of  the  lung  is  lower  than  normal 
in  shrinking  of  the  apex  in  consequence  of  tuberculosis. 

The  respiratory  movements  are  less  in  emphysema  and  brown  in- 
duration of  the  lungs,  in  beginning  pleurisy,  and  in  adhesion  of  both 
pleural  surfaces. 

DuLNESS  over  the  lung  substance  may  be  present  : 

1.  When  that  part  of  the  lung  next  to  the  thoracic  wall 
contains  no  air.  Still,  such  a  place  must  be  at  least  as 
large  as  the  pleximeter,  and  2  cm.  [i  inch]  thick,  in  or- 
der to  be  recognized.  The  parenchyma  of  the  lung  may 
be  without  air  in  pneumonia  and  tuberculous  infiltration, 
in  haemorrhagic  infarct,  abscess,  neoplasm  of  the  lungs, 
and  in  atelectasis  (by  compression  of  the  lung  or  by  an 
obstruction  in  the  bronchus  leading  to  it). 

2.  AVhen  a  fluid  or  solid  substance  (tumor,  pleuritic  ef- 
fusion) is  between  the  lung  and  the  thoracic  wall  ;  still, 
fluids  in  adults  must  amount  at  least  to  400  ccm.  [25  cu- 
bic inches]  in  order  to  be  found. 

'  Pleuritic  exudations  collect  in  a  non-adherent  pleural  cavity,  first  in 
the  posterior  inferior  parts,  and  extend  from  there  forward  and  up- 
ward. If  the  exudation  has  been  formed  while  the  patient  was  re- 
cumbent, the  upper  border  of  the  dulness  forms  an  inclined  line  from 
behind  and  above  to  in  front  and  below.     But  if  the  exudation  arise 


24  CLINICAL   DIAGNOSIS. 

while  the  patient  is  walking  about,  then  the  line  is  almost  horizontal. 
In  exudations  which  are  undergoing  absorption,  the  upper  border  of- 
ten has  a  curved  course,  which  is  highest  at  the  side  of  the  thorax 
(cur\-e  of  Damoiseau  or  Ellis). 

In  inflammatory  pleural  exudation  the  borders  of  the  dulness  change 
little  or  not  at  all  when  the  patient  changes  his  position,  since  the 
exudation  is  generally  encapsuled  by  the  adhesions  of  the  pleural  sur- 
face. In  hydrothorax,  which  is  generally  bilateral,  although  not  at 
the  same  height  on  both  sides,  the  level  of  the  fluid  changes  only  af- 
ter some  time.  In  a  collection  of  air  and  fluid  at  the  same  time  in  the 
pleural  sac  (pyo-  and  sero-pneumothorax)  the  border  of  the  fluid  be- 
comes horizontal  at  once,  since  in  the  upright  position  of  the  patient 
the  fluid  can  be  diagnosticated  as  a  dulness  in  the  anterior  inferior 
half  of  the  thorax,  while  in  the  supine  position  it  sinks  backward,  and 
makes  room  in  front  for  the  tympanitic  sound. 

The  other  organs  are  often  displaced  by  the  collection  of  large 
quantities  of  air  or  fluid  in  the  pleural  sac  The  displacement  of  the 
heart  is  not  so  great  in  left-sided  pleural  exudations  as  in  right-sided 
ones. 

A  tympanitic  sound  in  the  thorax  near  a  healthy  lung  is 
observed  in  the  lowest  part  only  of  the  left  lung  border- 
ing on  the  stomach. 

Pathologically,  a  tympanitic  sotmd  is  observed  : 

1.  In  condensatio7i  of  the  lung  tissue,  which  permits  of 
a  percussion  of  the  column  of  air  in  the  bronchi  and 
trachea,  that  is,  of  those  air  conductors  which  are  nor- 
mally present  in  the  lungs,  e,  g.,  in  infiltration  of  the 
upper  lobe. 

2.  In  the  presence  oi  pathological  Siir-condnctmg  cavi- 
ties. 

(a)  In  cavities  which  have  firm  walls,  or  in  those 
which,  with  smooth  walls,  are  separated  from  the  thoracic 
cavity  by  infiltrated  tissue,  e.  g.,  bronchiectatic  or  tuber- 
culous cavities,  when  these  are  at  least  as  large  as  a 
walnut. 


ORGANS   OF  RESPIRATION.  25 

{h)  \rv  pneumothorax,  so  long  as  the  air  is  not  under  too 
strong  pressure  ;  for  if  the  latter  is  the  case,  the  sound, 
which  was  before  tympanitic,  will  become  dull  and  non- 
resonant. 

3.  In  relaxation  of  the  lung  tissue  in  the  neighborhood 
of  extended  infiltrations  and  of  pleuritic  and  pericarditic 
exudations  ;  thus,  for  example,  there  is  often  heard  a 
tympanitic  sound  over  the  upper  lobe  of  a  lung,  when 
there  is  a  pneumonia  of  the  lower  lobe,  or  when  the  lung 
is  compressed  by  a  pleuritic  exudation. 

4.  In  incomplete  infiltrations  of  the  lung  tissue,  when 
it  contains  air  and  fluid,  as,  for  example,  in  the  first  and 
third  stages  of  croupous  pneumonia,  in  catarrhal  pneu- 
monia, and  oedema  of  the  lungs. 

A  metallic  soitnd  depends  upon  the  prominence  of  the 
high  upper  tones  together  with  the  fundamental  tone, 
and  gradually  decreasing  reverberation.  A  metallic 
sound  arises  in  the  thorax  from  the  presence  of  large 
smooth-walled  cavities  whose  diameter  is  at  least  6  cm. 
[2|- inches].  •     • 

The  cracked-pot sou7id  arises  on  strong  percussion  when 
the  air  is  forced  through  a  narrow  opening  out  of  a  cav- 
ity (murmur  of  stenosis).  It  is  also  found  in  healthy 
persons,  especially  in  children,  if  the  chest  is  percussed 
during  speaking  or  crying.  Pathologically  it  is  heard 
over  all  superficial  cavities  which  are  connected  with  the 
bronchi  by  a  narrow  opening,  and  at  times  also  when  the 
parenchyma  of  the  lung  is  relaxed  and  infiltrated.  This 
sound  is  clearer  on  strong  short  percussion  when  the  pa- 
tient opens  the  mouth.  If  this  sound  is  also  tinkling,  it 
is  called  metallic  tinkling. 

The  height  and  depth  of  the  percussion  ?iote  is  distin- 
guished principally  by  tympanitic  and  metallic  percus- 


26  CLINICAL   DIAGNOSIS. 

sion  note,  and  the  note  is  deeper  according  as  the  cavity 
is  larger,  and  the  opening  is  narrow. 

Wintrich' s  change  of  note  is  that  in  which  the  percus- 
sion note  is  higher  when  the  mouth  is  open,  and  lower 
when  it  is  closed.  It  is  observed  in  cavities  and  pneu- 
mothorax, if  they  are  in  open  communication  with  a 
bronchus,  except,  at  times,  in  pneumonia  and  pleuritic 
exudation  above.  If  this  change  of  sound  is  observed 
on  lying  down,  and  is  absent  on  sitting  up,  or  vice  versa, 
the  bronchus  leading  to  it  is  obstructed  in  certain  posi- 
tions by  the  fluid  contents  (interrupted  change  of  tone 
of  Wintrich). 

Respiratory  change  of  tone  is  at  times  observed  over 
cavities,  by  there  being  a  higher  tone  in  deep  inspira- 
tion. 

The  change  of  tone  of  Gerhardt,  that  is,  different  heights 
of  the  percussion  note  on  sitting  and  lying,  is  observed 
over  cavities  which  have  unequal  diameters  and  are 
partly  filled  with  fluid.  According  as  the  patient  sits  up- 
right or  lies  horizontally,  the  fluid  changes  its  position, 
and  thus  the  longest  diameter  of  the  (oval)  cavity,  which 
diameter  determines  the  height  of  the  tone,  is  made 
longer  or  shorter.  We  may  suppose  that  the  longest  di- 
ameter is  horizontal  when  the  percussion  note  is  deepest. 
The  most  reliable  sign  of  the  formation  of  a  cavity  is  to 
be  regarded  as  the  deeper  tone  on  sitting  up,  by  which 
the  longest  diameter  is  directed  from  before  behind. 

The  change  of  note  of  Bierjner  is  the  percussion  note  in 
a  pneumothorax  (containing  also  fluid)  which  is  deeper 
on  sitting  uj)  than  on  lying  down,  since  in  the  former 
position,  the  diaphragm  is  forced  down  by  the  pressure 
of  the  fluid,  and  thus  the  sounding  cavity  is  made 
larger. 


ORGANS  OF  RESPIRATION.  2/ 

Auscultation. 

The  Breathing  Sound. 

We  distinguish  : 

1.  Vesicular. 

2.  Bro7ichial. 

3.  Ampho7-ic. 

4.  Undetermined. 

5.  Metamorphosing. 

Vesicular  breathing.  Over  the  healthy  lung  is  heard, 
during  inspiration,  a  soft  sucking  murmur,  and  during 
expiration,  a  short  uncertain  or  vesicular  murmur,  or  none 
at  all.  In  children  we  find  an  especially  loud  and  sharp 
vesicular  respiration  :  puerile  respiration.  Vesicular 
breathing  represents  a  bronchial  breathing  which  origi- 
nates in  the  trachea  and  the  large  bronchi,  and  is  modi- 
fied by  the  overlying  lungs.  Vesicular  breathing  may  be 
imitated  by  saying/"  or  v  softly. 

A  diminution  of  vesicular  breathing  is  heard  in  obstruction  and 
narrowing  of  the  bronchi,  compression  of  the  lungs,  emphysema,  and 
also  when  the  kings  are  pressed  back  from  the  thoracic  wall  by  fluid 
(pleuritis),  or  solid  substances  (tumors). 

Increased  vesictilar  breathing  is  observed  in  the  swelling  and  nar- 
rowing of  the  bronchi,  e.  g.,  in  bronchial  catarrh. 

A  lengthening  and  sharpening  of  the  vesicular  expiratory  tone  is 
heard  when  the  exit  of  air  from  the  bronchi  is  prevented  by  swelling 
of  the  mucous  lining,  or  by  an  accumulation  of  the  secretion  in 
bronchitis  and  bronchial  asthma.  In  the  beginning  of  phthisis  pul- 
monum, the  same  thing  is  frequently  observed,  but  then  it  is  confined 
to  the  apices  of  the  lungs. 


When  the  inspiration  is  interrupted  by  two  or  more 
pauses,  we  call  it  jerking  respiration. 

A  systolic  vesicular  respiration  is  one  in  which  the  inspira- 
tory murmur  is  strengthened  with  each  heart  beat. 


2S  CLINICAL  DIAGNOSIS. 

Bronchial  bf^eathing,  or  sonorous  breathing,  which  cor- 
responds to  the  tympanitic  percussion  note,  is  heard,  in 
healthy  individuals,  over  the  larynx  and  trachea  and  inter- 
scapular space.  We  can  imitate  this  sound  by  pronoun- 
cing k  [the  German  ^/^].  It  is  stronger  and  lasts  longer  in 
expiration  than  in  inspiration. 

Under  pathological  conditions,  we  observe  this  kind  of  breathing 
wlien  the  respiratory  murniur  which  arises  in  the  larger  bronchi,  or 
in  smooth-walled  cavities,  is  transmitted  unchanged  through  consoli- 
dated lung  tissue  to  the  chest  wall,  as,  for  example,  in  pneumonia  or 
tuberculous  infiltration,  and  in  co77tpressio7t  of  the  lung  above  a 
pleural  exudation,  except  in  phthisical  or  bronchiectatic  cavities  which 
lie  near  the  thoracic  wall,  or  which  are  surrounded  by  consolidated 
tissue.  In  this  case,  the  bronchus  which  leads  to  it  must  be  unob- 
structed. 

Amphoi'ic  breathing  is  a  deep,  hollow,  buzzing  sound, 
heard  over  cavities  which  give  forth  a  metallic  percussion 
note,  e.  g.,  in  large,  smooth-walled  cavities  at  least  as  large 
as  the  closed  hand,  and  in  pneumothorax.  This  sound 
may  be  imitated  by  blowing  over  a  jug  or  a  bottle. 

An  undetermined  respiratory  murniur  is  one  which  has 
neither  the  character  of  bronchial  nor  vesicular  breath- 
ing. 

Metamorphosing  respiration  is  characterized  by  an  in- 
spiration which  begins  with  vesicular  breathing,  and  then 
passes  over  into  bronchial  breathing.  It  is  heard  princi- 
pally over  cavities. 

Rales 

are    respiratory  murmurs  caused    by    the    collection  of 
fluid  or  mucus  in  the  air  passages,  or  by  the  inspiratory 
current  of  air  which  forces  apart  the  adhering  bronchial 
walls.     We  distinguish  rales  according  as  they  are  : 
I.  More  or  less  plentiful. 


ORGANS   OF  RESPIRATION.  29 

2.  Moist  or  dry. 

3.  Mucous,  crepitant,  or  sub-crepitant. 

4.  Metallic  or  non-metallic. 

Dij  rales  may  be  purring  or  whistling  (sibilant  and 
sonorous).  These  are  heard  in  accumulation  of  a  thick 
secretion,  and  in  oedema  of  the  mucous  membrane. 

Moist  rales  d,rQ  divided  into  mucous,  crepitant,  and  sub- 
crepitant,  of  which  the  former  occur  only  over  large  cavi- 
ties, the  latter  over  smaller  ones.  Subcrepitant  rales  are 
heard  on  inspiration,  and  occur  in  the  first  and  third 
stages  of  pneumonia,  in  oedema  of  the  lung,  as  well  as  in 
persons  sick  or  convalescent,  who  have  been  for  some 
time  in  a  recumbent  position,  in  whom  the  crepitant  rale 
is  heard  in  the  posterior,  inferior  part  of  the  lung,  during 
the  first  deep  inspiration. 

Metallic  rales  are  heard  under  the  same  circumstances 
as  bronchial  breathing  over  consolidated  lung  tissue, 
cavities,  etc. 

Metallic  tinkling  rales  of  high  musical  pitch  are  heard 
over  large  cavities  which  give  forth  a  metallic  percussion 
note  and  amphoric  breathing.  To  this  class  belongs  the 
sound  of  drops  of  fluid  falling  into  the  cavity,  as  in 
pneumothorax. 

Auscultation  of  the  Voice. 

On  auscultating  the  chest  of  a  healthy  person  while 
talking,  the  only  thing  heard  is  an  indistinct  murmur. 

This  auscultatory  sign  is  weakened  by  obstrtcction  or  compression 
of  the  bronchi,  or  by  a  layer  of  air  or  fluid  between  the  chest  wall 
and  the  lung  (pleurisy,  pneumothorax,  etc.). 

Bronchophony^  or  increased  transmission  of  the  voice,  is 
heard  where   the   sound  waves  of  the  broncho-tracheal 


30  CLIXICAL   DIAGXOSIS. 

column  of  air  are  conducted  through  the  consolidated 
lung  tissue  to  the  chest  wall,  e.  g.,  in  pneumonia,  cavities, 
above  a  pleuritic  exudation,  etc.  Very  strong  bronchoph- 
ony is  cs^Q^L  pectoriloquy . 

A  special  kind  of  bronchophony  is  called  cBgophony^  by 
which  we  understand  a  high  trembling  or  bleating  variety 
of  voice.  This  is  observed  more  frequently  in  incomplete 
compression  of  the  bronchi  at  the  upper  border  of  a  me- 
dium-sized pleuritic  exudation,  less  frequently  in  hydro- 
thorax  as  well  as  over  infiltrated  lung  tissue  and  cavities. 

A  metallic  sound  of  the  voice  is  heard  over  large  cavi- 
ties, and  pneumothorax. 

Succusßio  Jlippocratis,  or  a  metallic  splashing,  is  heard 
when  air  and  fluid  are  present  in  the  pleural  cavity  at  the 
same  time,  if  the  patient  be  taken  by  the  shoulders  and 
shaken,  as  in  sero-  and  pyopneumothorax.  A  dull  or 
cooing  sound  is  also  occasionally  heard  over  phthisical 
or  bronchiectatic  cavities. 

Pleuritic  friction  is  heard  when  the  pleural  surfaces 
which,  in  a  normal  condition  are  smooth  and  shining,  are 
roughened  by  fibrinous  deposits,  tubercular  eruption,  or 
abnormal  dryness,  and  the  pulmonary  surface  of  the 
pleura  rubs  against  the  parietal  surface  during  respira- 
tion. On  adhesion  of  both  pleural  surfaces  no  friction 
sound  is  heard.  The  friction  sound  is  grenerallv  of  a 
jerking  character,  and  is  either  soft  or  creaking. 

It  is  closely  connected  with  respiration  and  ceases  on 
holding  the  breath.  It  is  distinguished  from  dry  rales 
by  being  less  regular,  is  not  influenced  by  coughing,  and 
is  increased  by  pressure  on  the  intercostal  spaces. 
Further  it  appears  to  be  more  superficial  and  nearer  the 
ear.  It  is  strengthened  by  a  strong  inspiration.  The 
pleuritic  friction  is  often  to  be  felt  on  palpation, 


ORGANS   OF  RESPIRATION.  31 

The  vocal  fremitus,  or  pectoral  fremitus,  is  the  vibration 
of  the  voice  transmitted  through  the  bronchi  and  lung 
tissue  to  the  chest  wall.  It  is  felt  by  laying  both  hands 
symmetrically  on  the  chest  wall  while  the  patient  speaks. 
The  strength  of  the  vocal  fremitus  is  dependent  upon  the 
strength  and  depth  of  the  voice,  and  upon  the  amount  of 
resistance. 

Increase  of  vocal  fremitus  occurs  in  infiltration  and  compression 
of  a  circumscribed  portion  of  the  lung  when  the  bronchus  leading  to 
this  part  is  unobstructed.  It  is  noticed  in  pneumonia,  above  pleural 
exudations,  as  well  as  over  cavities  with  consolidated  walls. 

Decrease  and  absence  of  the  vocal  fremitus  occurs  in  very  weak  or 
absent  voice,  in  obstruction  or  stenosis  of  the  bronchus  leading  to 
that  part  where  the  chest  wall  is  unusually  thick,  and  where  there  is 
a  layer  of  air  or ßuid  between  the  lung  and  chest  wall,  principally 
over  pleuritic  exudations  and  pneumothorax.  Still,  in  pleuritic 
adhesions  between  the  lung  and  the  chest  wall,  the  vocal  fremitus 
within  the  region  of  a  pleuritic  exudation  or  a  pneumothorax  may  be 
partly  present,  or  even  increased. 


CHAPTER  IV. 
THE  SPUTUM. 

The  sputum  consists  not  only  of  the  secretion  of  tlie 
tracheal  and  bronchial  mucous  membrane,  as  well  as  of 
the  pus  from  the  cavernous  portions  of  the  respiratory 
tracts,  but  also  it  consists  of  the  secretions  of  the  pharynx 
and  nasal  cavity,  as  far  as  this  is  expectorated  ;  also  it 
consists  of  the  saliva  and  the  secretion  of  the  mucous 
membrane  of  the  mouth.  The  remains  of  food  are  often 
mixed  with  the  sputum. 

According  to  the  prmcipal  constituents  of  the  sputum, 
it  is  divided  into — 

1.  Mucous, 

2.  PiLrulent, 

3.  Serous, 

4.  Bloody^ 

and  the  combined  kinds,  or  muco-purulejit  (principally 
mucous),  purulo-mucous  (principally  pus),  sanguiiieo- 
mucous,   smigidneo-serous,   etc. 

We  also  distinguish  according  as  the  different  con- 
stituents are  intimately  mixed  with  the  mucus  or  not. 

Pure  miicoiis  sptita  are  found  principally  in  incipient  bronchitis. 
The  sputa  also  of  the  vault  of  the  pharynx  are  very  thick  and  often 
consist  of  dried  mucous  masses. 

Pure  puruletit  sputa  are  found  in  rupture  of  abscesses  of  the  lung 
or  neighboring  organs,  or  from  empyema  of  the  bronchi. 

Se7'ous  foamy  sputa  are  observ^ed  in  oedema  of  the  lungs. 

Sanguineo-mucous  sputa,    intimately    mixed  (brick-red    to    rust- 

33 


THE   SPUTUM.  33 

Colored),  are  found  in  pneumonia,  hemorrhagic  infarct,  and  car- 
cinoma of  the  lung  (raspberry-jelly  sputa)  ;  sanguineo-serotis  sputa 
(prune-juice  sputa)  are  seen  in  oedema  of  the  lung  in  the  course  of 
croupous  pneumonia.  This  latter  is  not  to  be  confounded  with  the 
blood-colored  sputa  (brown-red,  with  a  stale  smell)  which  are  often 
expectorated  by  malingerers  and  hysterical  persons. 

Muco-purulent  sputa,  intimately  mixed,  are  found  in  diffuse 
bronchitis  and  broncho-blennorrhoea,  and  in  the  latter  disease  the 
sputum  divides  in  the  spit-cup  into  three  layers.  In  phthisis  pul- 
monum the  sputum  is  generally  purulo-mucous  and  not  mixed,  while 
the  pus  is  in  streaks  or  balls,  or  nummular,  and  surrounded  by 
mucus.  In  very  large  cavities  the  sputum  may  run  together  and  be 
mixed. 

Pure  bloody  sputa  (haemoptysis)  occur  when  a  blood-vessel,  or  even 
a  small  aneurism  in  the  neighborhood  of  the  respiratory  organs,  is 
eaten  through  by  ulcerations.  The  blood,  in  this  case,  differs  from 
the  blood  in  hemorrhage  from  the  stomach  principally  by  its  being 
bright  red  and  not  mixed  with  food. 

The  consistency  of  the  sputa  is  dependent  upon  the 
amount  of  mucus  in  it,  and  not  upon  the  solid  sub- 
stances. 

Smell.  A  foul  smell  is  caused  by  decomposition  in  the 
bronchi  and  the  lungs  (foetid  bronchitis,  gangrene  of  the 
lung) 

Colo?'.  Apart  from  the  yellow-greenish  color  caused 
by  the  presence  of  pus,  we  may  have  red,  brown,  or  yel- 
low-greenish color  due  to  more  or  less  changed  condition 
of  the  blood-coloring  substance,  as  in  haemoptysis,  infarct 
of  the  lungs,  pneumonia,  etc. 

K  yellow-ochre  color  of  the  sputum  is  observed  from  the 
presence  of  haematoidin,  as  in  abscess  of  the  lung. 

A  green  color  may  be  caused  by  the  coloring  matter  of 
the  gall  (^.  g.,  pneumonia  with  icterus),  by  micro-organ- 
isms causing  decomposition. 

Blue-colored  sputa  are  seen  in  workmen  in  dyeworks  ; 


34  CLINICAL  DIAGNOSIS. 

black  sputa  in  those  who  inhale  much  coal  dust  or  soot  ', 
also  in  iron-workers.  In  the  latter  we  find  occasionally 
ochre-colo7'ed  and  red  sputa. 

Sputa,  the  color  of  the  yolk  of  an  egg,  are  seen  in  con- 
sequence of  bacteria. 

The  reaction  of  the  sputa  is  generally  alkaline. 

The  amoinit  varies  according  to  the  cause.  Especially 
large  quantities  are  observed  in  broncho-blennorrhoea,  in 
large  bronchiectatic  and  tuberculous  cavities,  and  in 
oedema  of  the  lung. 

Morphological    Constituents. 

Leucocytes  are  observed  as  a  constancy  in  sputum,  and 
they  are  the  more  abundant,  the  more  the  sputum  is  of 
a  purulent  character.  They  are  often  in  process  of  dis- 
integration if  they  are  old  or  if  decomposition  has  set  in, 
as  in  foetid  bronchitis,  gangrene  of  the  lung,  bursting  of 
empyema,  etc. 

Pavement  epiiheliuni  is  from  the  mouth  cavity  and  from 
the  true  vocal  cords. 

Cylindrical  epitheliimi  may  come  from  the  nasal  cavity 
from  the  upper  part  of  the  pharynx,  the  larynx,  and 
bronchi.  They  are  seldom  observed  in  the  sputum,  and 
then  only  in  acute  catarrh  of  the  mucous  membranes  just 
mentioned. 

Alveolar  epitheliiwi  (whose  source  in  the  alveoli  of  the 
lungs  and  in  the  finest  bronchi  has  not  been  surely 
proved)  are  the  large  round  or  oval  cells  with  vesicular 
nucleus  ;  and  in  the  protoplasm  are  often  seen  particles 
of  fat,  of  coal,  and  myeline.  These  cells  are  occasionally 
colored  yellow-brown  by  the  coloring  matter  of  the  blood 
(in  brown  induration  of  the  lung  and  infarct).  They  are 
of  no  diagnostic  importance. 


THE   SPUTUM,  35 

Ked  blood  corpuscles  : 

Bronchial  casts  of  fibrin  are  expectorated  in  fibrinous 
bronchitis  and  croupous  pneumonia. 

CurscJimann  s  corkscrew  spiral  threads  with  a  bright 
axis-cylinder  are  observed  in  capillary  bronchitis,  and  in 
bronchial  asthma.  They  may  generally  be  recognized 
with  the  unaided  eye  as  fine  threads,  and  are  often  seen 
in  small  sago-like  clumps  of  mucus. 

Elastic  fibres  are  observed  in  the  sputum  in  all  destruc- 
tive diseases  of  the  air  passages,  and  especially  in  phthi- 
sis pulmonum  and  abscess  of  the  -lungs.  In  gangrene  of 
the  lungs  the  elastic  fibres  are  absent,  because  there  is  in 
this  disease  a  ferment  present  which  dissolves  the  fibres- 
In  order  to  show  the  elastic  fibres,  it  is  generally  sufficient 
to  mix  a  suspicious  part  of  the  sputum  on  a  slide  with  a 
drop  of  a  lo  f^  solution  of  caustic  potash,  and  then  to  ex- 
amine it.  Also  a  larger  amount  of  sputum  may  be  heated 
with  an  equal  amount  of  a  lo^  caustic  potash  solution, 
and  left  standing  in  a  glass  with  sloping  sides  until  a  sedi- 
ment forms,  which  may  be  examined  under  the  micro- 
scope.    Elastic  fibres  occasionally  come  from  the  food. 

Shreds  of  the  parenchyma  of  the  lung  are  especially 
noticeable  in  abscess  and  gangrene  of  the  lung. 

Fatty  acid  crystals  and  fine  curved  colorless  crystals  are 
found  in  putrid  bronchitis,  abscess  and  gangrene  of  the 
lung.  They  melt  to  fat  on  heating  the  slide.  They  are 
found  most  frequently  in  yellow-white  foul-smelling 
clumps,  as  large  as  a  pin's  head  and  larger. 

Hcematoidi?i  appears  in  amorphous  yellow-brownish 
grains,  or  in  rhombic  plates  and  undulating  needle-like 
crystals  of  the  same  color.  It  is  seen  in  old  blood  ex- 
travasations, and  in  the  lungs,  and  in  abscess  of  the 
lungs  and  neighboring  organs. 


2,6  CLINICAL  DIAGNOSIS. 

The  Charcot-Leyden  cj-ystals  -ixxit  jDointed,  colorless,  shin- 
ing octahedra,  and  are  especially  found  in  bronchial 
asthma.  They  are  seen  most  easily  in  the  yellow  fatty 
flakes  and  streaks  in  the  sputa. 

Crystals  of  cholestejine.,  leucine,  and  txrosiiie  are  seen 
occasionally  in  abscess  of  the  lung  and  in  putrid  expec- 
toration. 

Of  animal  parasites  are  found  in  the  sputum  principally 
echinococcus  hydatids  and  the  ova  of  distomum. 

Micro-organisms  are  present  in  all  sputa,  but  are  es- 
pecially abundant  in  putrid  decomposition.  Of  especial 
importance  are  the  bacilli  of  tuberculosis  and  of  anthrax. 
In  order  to  examine  for  the  bacilli  tuberculosis,  parts  are 
taken  from  the  sputa,  free  from  pus  of  such  a  kind  as  seems 
to  come  from  a  cavity.  For  directions  how  to  prepare  and 
color  preparations,  see  Chapter  XI.  The  examination  for 
the  coccus  of  pneumonia  has,  as  yet,  reached  no  diagnostic 
importance.  Now  and  then  threads  of  asper^illus  (pneu- 
monomycosis  aspergillina)  are  found  in  the  sputum. 
These  are  best  recognized  in  a  preparation  which  has 
been  treated  with  a  lo  ^^  caustic  potash  solution.  Also 
leptothrix  threads,  which  are  stained  blue  by  a  solution 
of  iodine  in  iodide  of  potash,  and  sarcinse,  as  well  as  the 
rosettes  of  actinomycosis  are  all  occasionally  found  in 
the  sputum. 


CHAPTER  V. 
LARYNGOSCOPY. 

The  larynx  is  situated  between  the  upper  border  of  the 
3d,  and  lower  border  of  the  6th  cervical  vertebra  during 
rest,  and  rises  and  falls  during  respiration,  phonation,  and 
deglutition.  Very  great  respiratory  excursions  are  made 
in  stenosis  of  the  larynx,  when  the  head  is  inclined  back- 
ward. Very  few  or  no  respirations  are  made  in  stenosis 
of  the  trachea,  when  the  position  of  the  head  is  inclined 
forward. 

T\\Q  percussion  of  the  larynx  gives  a  tympanitic  sound, 
a  higher  tone  when  the  mouth  is  open,  and  a  deeper  one 
when  the  mouth  is  closed.  The  aiLscultation  of  the  larynx 
and  trachea  gives  loud  tubal  respiration  which  is  called 
laryngo-tracheal  respiration. 

Voice. 

We  distinguish  :  (i)  An  open  and  d^  closed  nasal  voice ^  the 
former  when  (in  paralysis  or  perforation  of  the  soft  pal- 
ate) the  closing  of  the  posterior  nares  is  impossible,  and 
the  latter,  when  the  nose  is  impermeable  to  air  and  is 
obstructed,  (polypi,  tumors,  and  stopping  of  the  nose  by 
coryza)  ;  (2)  A  Jioarse  voice  or  one  accompanied  by  dis- 
turbing accessory  sounds  ;  (3)  A  iveak  voice  ;  and  (4)  A 
want  of  voice  (aphonia,  the  voice  is  without  sound)  ;  (5) 
Falsetto  voice  j  (6)  Bass  (an  unnaturally  deep  voice  in 
destruction  of  the  vocal  cords)  ;  (7)  Diphthonia  j  and 
(8)   Tripartite  voice  in  polypi  of  the  vocal  cords. 

37 


38  CLINICAL   DIAGNOSIS. 

The  Muscles  of  the  Larynx. 

The  larynx  is  raisedh^T  the  hyo-thyroid,  and  drawn  down 
by  the  sterno-thyroid  ;  the  epiglottis  is  raisedhj  the  thyro- 
epiglottic, and  lowered  by  the  ary-epiglottic  muscles. 

The  widening  of  the  vocal  chink  (abduction  of  the  vocal 
cords)  is  carried  out  by  the  posterior  crico-arytenoid  mus- 
cle. The  same  muscle  turns  the  processus  vocalis  of  the 
arytenoid  cartilage  outward. 

The  closure  of  the  vocal  cords  (adduction  of  the  vocal 
cords)  is  carried  out  by  the  lateral  crico-arytenoid  mus- 
cle, which  turns  the  processus  vocalis  inward,  and  by  the 
inter-arytenoid  muscle  (transverse  and  oblique),  which 
draws  the  base  of  the  arytenoid  cartilages  to  each  other. 

The  tension  of  the  vocal  cords  is  maintained  by  the 
crico-thyroid,  which,  by  fixation  of  the  cricoid  cartilage, 
moves  the  thyroid  cartilage  forwards  and  upwards. 
Further,  it  is  caused  by  the  thyro-arytenoid  muscles,  the 
actual  muscles  of  the  vocal  cords. 

Nerves  of  the  Larynx. 

These  spring  from  the  vagus,  and  the  motor  branches 
are  very  likely  originally  from  the  accessorius.  The 
superior  laryngeal  nerve  supplies  the  crico-thyroid  muscle 
with  motor  branches  by  its  external  branch  ;  by  its  inter- 
nal branch,  the  muscles  of  the  epiglottis  ;  with  sensory 
fibres  the  mucous  membrane  of  the  larynx.  The  inferior 
laryngeal  nerve  (recurrens  nervi  vagi)  on  the  right  side 
curves  backward  around  the  subclavian  artery,  on  the  left 
side  around  the  arch  of  the  aorta,  goes  upward  between 
the  trachea  and  oesophagus,  and  supplies  all  the  remain- 
ing muscles  not  supplied  by  the  superior  laryngeal 
nerve. 


LAR  YNGOSCOP  Y. 


39 


According  to  recent  investigations  of  Exner '  there  exists,  besides 
the  superior  and  inferior  laryngeal  nerves,  a  median  laryngeal  nerve, 
which  springs  from  the  plexus  pharyngeus.  The  motor  and  sensory 
division  of  the  nerves  is  less  simple  than  the  above  description. 

Paralysis  of  the  Vocal  Cords. 

In  paralysis  of  the  posterior  crico-aiytenoid  musck,  the 
vocal  cord  cannot  be  moved  outwards  in  respiration. 
The  paralyzed  vocal  cord  remains,  during  respiration, 
near  the  median  line. 

In  paralysis  of  both  cords  (Fig.  19,  a)  there  is  a  small 
crack  only  between  them,  and  there  arises  inspiratory 
dyspnoea.      This  same  thing  occurs  in  spasm  and  contrac- 

Fig.  19. 


Paralysis  of  them,  crico-  Paralysis    of    the  Paralysis  of  the 

arytrenoideus       posticus.        inter- arytrenoideus.  thyro-arytsenoi- 

Positioii  of  inspiratiou.  Phonation.  deus.  Phonation. 


Paralysis  of  the  recur- 
rent laryngeal  on  both 
sides.  Respiration  and 
Phonation. 


tion  of  the  adductor  muscles  (lateral  crico-arytenoid  and 
inter-arytenoid). 

In  paralysis  of  the  inter-arytenoid^  the  arytenoid  carti- 
lages may  approach  each  other  with  their  processus 
vocales  (lateral  crico-arytenoid),  but  not  with  bases,  and 
therefore  in  phonation  there  remains  in  the  posterior 
third  of  the  glottis  (glottis  respiratoria)  an  open  triangle 
(Fig.  19,  b) 

In  paralysis  of  the  thyro-arytenoid^  the  tension  of  the 
vocal  cord  on  phonation   is  incomplete,  and  the  chord 

*  Sitzungsber.  der  Kaiserl.  Akad.  d.  Wissensch.,  89,  i  u.  2.  Wien, 
1884. 


4Ö  CLINICAL  DIAGNOSIS. 

bowed  outward  with  its  free  edge  concave  (Fig.  19,  ^.). 
When,  in  addition  to  this,  there  is  paralysis  of  the  inter-ajy- 
fmoi'd  muscles,  the  chink  remains  open, 
and  the  processus  vocales  in  front  are 
bowed  out.     (Fig.  19,  <?.) 

In  paralysis  of  the  adductors  (lateral 
crico-arytenoid  and  inter-arytenoid),  the 
Paralysis  of  the  Mm.    glottis  rcmaius  opeii  as  a  large  triangle 

thyro-arvtrenoidei  and  in-  .  .  a  ^ 

ter-arytinoidei.  qu  phouatiou  (Fig.  1 9  ^/.)      lu  paralysis 

of  the  lateral  crico-arytenoid  alone,  the  glottis  has  a 
lozenge  shape. 

In  double-sided  paralysis  of  the  recui-rent  nerve,  both 
vocal  cords  are  immovable  in  the  halfway  position  in 
Phonation  as  well  as  in  respiration  (Fig.  19,  ^.),  the  posi- 
tion after  death.  In  paralysis  of  this  nerve  on  one  side, 
the  healthy  vocal  cord  moves  in  respiration  outward 
normally,  and  in  phonation  it  approaches  the  paralyzed 
cord  by  crossing  of  the  arytenoid  cartilages. 

In  paralysis  of  the  crico-thyroid  the  vocal  cord  paralyzed 
is  deeper  than  the  healthy  cord  on  phonation.  Also  in 
paralysis  of  the  superior  laryngeal  nerve,  there  is  immo- 
bility of  the  epiglottis  on  that  side  as  well  as  anaesthesia 
of  the  mucous  membrane  of  the  epiglottis  (absence  of  re- 
flex, swallowing  the  wrong  way). 


CHAPTER  VI. 
CIRCULATORY    SYSTEM. 
Inspection  and  Palpation. 

The  apex  beat  of  the  heart.  The  5th  intercostal  space 
on  the  left  side  between  the  parasternal  and  mammary 
line,  is  where  the  apex  beat  of  the  heart  is  to  be  found  in 
healthy  individuals.  In  children  it  often  lies  in  the  4th 
intercostal  space  and  more  outward,  and  in  old  people  it 
lies  in  the  6th  intercostal  space.  The  apex  beat  is  lower 
during  a  deep  inspiration,  and  lies  more  to  the  left,  when 
the  individual  lies  on  the  left  side. 

The  apex  beat  is  lower  down  in  hypertrophy  of  the  left  ventricle, 
aneurism  of  the  aorta,  and  when  the  diaphragm  is  lower,  as  in  em- 
physema and  pneumothorax. 

The  apex  heat  is  high  when  the  diaphragm  is  pressed  upward  by 
abdominal  tumors,  ascites,  tympanites,  and  contraction  of  the  left 
lung. 

Movement  of  the  apex  beat  and  of  the  cardiac  dulness  to  the  right  is 
observed  in  pleural  exudation  of  the  left  side,  and  in  pneumothorax 
or  in  contraction  of  the  right  lung.  The  apex  beat  lies  more  to  the 
left  in  hypertrophy  and  dilatation  of  the  heart,  in  collections  of  fluid 
and  air  in  the  pericardium,  and  when  the  mediastinum  is  pressed  to 
the  left. 

The  apex  beat  may  be  of  normal  strength,  or  weak- 
ened (or  even  absent),  or  increased,  that  is  : 
{a)  Simply  strengthened. 
(^)  Shaking. 
{c)  Heaving. 

41 


42  CLINICAL   DIAGNOSIS. 

A  weakening  of  the  apex  beat  is  observed  when  the  heart  is  unable 
to  do  its  work  (degeneration  of  the  heart  muscle,  fatty  heart)  and 
Avhen  the  heart  is  pressed  backward  from  the  chest  wall  by  air  or  fluid 
in  the  pericardium  or  by  an  emphysematous  lung. 

Increased  stretigth  of  the  apex  beat  is  observed  in  increased  activity 
of  the  heart  (fever,  mental  excitement,  exercise)  and  hypertrophy  of 
the  left  ventricle.  In  the  latter  case,  the  apex  beat  is  below  and  out- 
ward, whereas  in  hypertrophy  of  the  right  ventricle,  the  apex  beat  is 
extended  toward  the  right  side. 

Cardiac  7fiove?nent,  visible  to  a  greate?-  extent,  is  seen  in 
materially  increased  heart  action,  and  when  the  heart  is 
in  contact  with  the  chest-wall  to  a  greater  extent,  as  in 
contraction  of  the  left  lung. 

In  advanced  hypertrophy  and  dilatation  of  the  heart, 
and  in  pericarditis,  the  caj'diac  region  projects  forward 
(voussure). 

A  sinking  in  of  the  chest  at  the  apex  during  the  systole 
denotes  adhesions  of  the  heart  with  the  pericardium. 

Pulsation  in  the  epigasti'iiun  occurs  in  hypertrophy  of 
the  right  ventricle,  and  when  the  diaphragm  is  low. 

Pulsation  of  the  ascendi7ig  aorta  in  the  second  right  in- 
tercostal space,  as  well  as  of  the  pulmonary  artery  in  the 
second  left  intercostal  space,  is  observed  in  enlargement 
(aneurism)  of  these  vessels,  as  well  as  in  thickening  of 
the  borders  of  the  lungs.  When  the  closure  of  the  valve 
of  the  pulmonalis  may  be  felt  on  palpation,  it  is  regarded 
as  pathological,  and  is  caused  by  stasis  in  the  lesser  cir- 
culation. 

Also  in  the  heart  region,  pe?'icar dial  friction  and  a  sys- 
tolic or  diastolic  buzzing  sound  may  be  felt  at  all  the 
valves,  and  the  latter  has  the  same  importance  as  the 
murmur  to  which  it  corresponds. 

Pulsation  in  the  bulb  of  the  Jugular  vein  is  an  important 
sign  in  insufficiency  of  the  tricuspid.     This  pulsation  is 


CIRCULATORY  SYSTEM.  43 

synchronous  with  the  systole,  and  shows  that  the  bulbus 
valves  are  incapable  of  closing,  on  account  of  the  exten- 
sion into  the  jugular  vein  of  the  pulsation.  Venous  pulse 
may  be  seen  in  the  arm  and  in  the  liver,  as  in  the  case  of 
a  pulsation  extending  over  the  whole  liver,  and  especially 
over  the  right  lobe.  A  presystolic  venous  pulse  is  ob- 
served in  overfilling  of  the  right  heart  when  the  tricuspid 
valve  is  intact.  An  abnormal  fulness  of  all  the  veins 
{cyanosis)  is  seen  when  the  heart  is  barely  able  to  work 
(valvular  disease)  or  in  obstruction  in  the  lesser  circula- 
tion. 

Diastolic  collapse  of  the  veins  may  occur  in  pericardial 
adhesion. 

A  capillary  pulse  is  seen  in  hypertrophy  of  the  left  ven- 
tricle (especially  in  insufficiency  of  the  aorta)  when  the 
finger  is  drawn  across  the  forehead. 

Percussion  of  the  Heart. 

Cardiac  dulness.  In  healthy  individuals,  the  heart  dul- 
ness  begins  above,  at  the  lower  border  of  the  fourth  rib  ; 
the  inner  boundary  is  on  the  left  border  of  the  sternum^ 
the  outer  boundary  is  formed  by  a  line  drawn  from  the 
fourth  costal  cartilage,  curving  convexly  around,  and  end- 
ing at  the  apex  beat.  The  inner  and  under  side  of  the 
heart  dulness  measures  5-6  cm.  [2-2J  inches].  In  chil- 
dren, the  heart  dulness  is,  relatively,  somewhat  greater, 
and  in  the  aged,  smaller.  On  deep  respiration  the  heart 
dulness  is  decreased  in  size  except  in  adhesions  of  the  left 
lung.  When  the  patient  is  on  the  left  side,  the  heart  dul- 
ness lies  more  outward.  Increase  of  the  heart  dulness 
occurs  in  hypertrophy  and  dilatation  of  the  heart. 

The  dulness  is  increased  from  above,  downwards  and 
outwards  in  hypertophy  and  dilation  of  the  left  ventricle. 


44  CLINICAL   DIAGNOSIS. 

while  in  hypertrophy  and  dilatation  of  the  right  ventricle 
the  heart  dulness  is  broader  and  lies  over  the  right  side 
of  the  heart. 

Hypertrophy  of  the  left  ventricle  is  observed  in  insufficiency  of  the 
aortic  and  mitral  valve,  in  stenosis  of  the  aortic  valve  (without  dilata- 
tion), in  aneurism  of  the  aorta  and  atheroma  of  the  arteries,  in 
nephritis,  and  after  long-continued  and  excessive  bodily  exertion. 

Hypertrophy  of  the  right  ventricle  begins  in  an  overloading  or  in 
obstruction  in  the  pulmonary  circulation  (mitral  insufficiency  and 
stenosis,  emphysema,  contraction  of  the  lung,  defects  in  the  pulmo- 
nary valves,  and  in  insufficiency  of  the  tricuspid). 

Increase  of  heart  dulness  in  length  and  breadth  occurs 
when  the  whole  heart  is  hypertrophied,  or  when  there  is 
an  effusion  into  the  pleural  cavity.  In  the  latter  case, 
the  dulness  is  in  the  form  of  an  equilateral  triangle 
whose  apex  lies  in  the  3d-ist  intercostal  space,  and, 
which  lies  on  the  right,  beyond  the  right  sternal  border, 
and  on  the  left,  beyond  the  apex  beat. 

There  is  also  increase  of  the  heart  dulness  in  retraction 
of  the  left  lung,  chlorosis,  and  in  fatty  degeneration  of 
the  heart,  and  when  the  heart  is  pressed  against  the  an- 
terior chest-wall  by  pressure  upward  of  the  diaphragm 
(by  pregnancy,  by  tumors  of  the  mediastinum,  etc.). 

An  apparent  enlargement  of  the  heart  dulness  occurs  in 
infiltration  of  the  left  lung,  and  in  a  pleural  exudation  of 
the  left  side, 

A  decrease  in  area  of  the  heart  dulness  occurs  in  atrophy 
of  the  heart  and  in  emphysema.  On  presence  of  air  in  the 
pericardium,  there  is  observed,  when  the  patient  lies  on 
the  back,  instead  of  heart  dulness  a  tympanitic  or  metallic 
sound,  which  changes  its  seat  as  the  patient  moves. 

When  the  ductus  arteriosus  Botalli  remains  open,  the  heart  dulness 
is  in  the  shape  of  a  small  quadrilateral  figure, 


CIRCULATORY  SYSTEM.  45 

In  case  of  situs  viscerum  transversus,  the  heart  dulness  and  apex 
beat  are  found  in  the  corresponding  place  on  the  opposite  side. 

Aneurisms  of  the  ascending  aorta  cause  dulness  and  pulsation  at 
the  second  and  third  sterno-costal  articulation  of  the  right  side. 
Aneurisms  of  the  arch  and  of  the  pulmonary  artery  cause  the  corre- 
sponding appearances  on  the  left  side. 

Auscultation  of  the  Heart. 

Six  sounds  are  heard  over  the  heart,  A  systolic  sound 
from  each  venous  opening  (mitral  and  tricuspid  valves), 
a  systolic  and  diastolic  tone  from  the  arterial  openings 
(aorta  and  pulmonary).  The  systolic  sound  begins  with 
the  contraction  of  the  ventricle,  the  diastolic  with  the 
beginning  of  the  relaxation  of  the  heart,  and  the  closing 
of  the  aorta  and  pulmonary  valves. 

The  mitj^al  is  auscultated  over  the  apex  beat  ;  the  tricus- 
pid^ at  the  right  sternal  border  at  the  fifth  and  sixth  cos- 
tal cartilage  ;  the  aortic^  at  the  second  intercostal  space, 
on  the  right  side  near  the  sternum  ;  and  the  pulmonary 
valves  in  the  second  intercostal  space  on  the  left  side, 
very  near  the  sternum. 

Two  sounds  are  heard  at  each  opening.  The  second 
sound,  at  the  mitral  and  tricuspid,  is  transmitted  from 
the  aorta  and  pulmonalis.  Over  the  ventricles  the  accent 
is  on  the  first  sound  (trochseus),  over  the  great  vessels  it 
is  on  the  second  sound  (iambus).  The  second  aortic 
sound  is  normally  as  strong  as  or  even  stronger  than  the 
second  pulmonary  sound. 

A  strengthened  first  sound  is  heard  when  the  work  of  the  heart 
is  increased,  in  hypertrophy  of  the  ventricle  in  chlorosis,  in  mitral 
stenosis,  also  in  fever. 

A  weakened  first  sound  occurs  in  weak  conditions,  in  degeneration 
of  the  heart  musculature,  and  in  emphysema. 

Strengthening  of  the  second  aortic  sound,  occurs  on  increased  arte- 
rial pressure  [e.  g.,  nephritis),  and  in  atheroma  of  the  aorta. 


46  CLINICAL   DIAGNOSIS. 

A  strengthened  second  pulmonary  tone  is  heard  in  over-distension 
of  the  cavities,  in  obstruction  in  the  lesser  circulation  (mitral  insuffi- 
ciency, stenosis  and  emphysema,  and  cirrhosis  of  the  lung).  In  mitral 
troubles,  the  strengthened  second  pulmonary  sound  is  wanting  as 
soon  as  the  tricuspid  insufficiency  begins. 

Metallic-sou7iding  heart  tones  are  heard  at  times  over 
lung  cavities,  in  pneumopericardium,  and  dilatation  of 
the  stomach. 

Reduplication  of  the  heart  sounds  is  occasionally  ob- 
served in  health  (depending  upon  respiration)  in  un- 
equal tension  of  the  column  of  blood  in  both  ventricles, 
which  causes  the  valves  on  both  sides  to  close  at  differ- 
ent times. 

\  reduplication  of  the  first  sound  \'=i  observed  in  hyper- 
troph}^ of  the  left  ventricle,  especially  as  a  consequenc  of 
granular  atrophy  of  the  kidneys.  A  reduplication  of  the 
second  sound  at  the  arterial  openings  is  due,  among  other 
reasons,  to  mitral  stenosis. 

The  Heart  Murmurs. 

Systolic  murmurs  are  those  heard  from  the  beginning 
of  the  first  heart  sounds  to  the  beginning  of  the  second 
heart  sounds,  and  all  raurmnrs  from  this  point,  to  the 
first  sound  again,  are  called  diastolic.  A  diastolic  mur- 
mur which  is  heard  immediately  before  the  beginning 
of  the  next  systolic,  is  called  2. presystolic  murmur.  The 
murmurs  are  heard  after  the  sound  or  instead  of  the 
normal  heart  sound.  These  murmurs  may  be  confined 
to  one  heart  phase,  or  they  may  continue  from  the  one 
to  the  next.  The  character  of  the  murmur  may  be 
breathing,  blowing,  rasping,  gushing  (a  diastolic  murmur 
in  aortic  insufficiency),  groaning,  etc. 

The  strength  of  a  murmur  is  in  proportion  to  the  swift- 


CIRCULATORY  SYSTEM.  47 

ness  of  the  blood  current,  and  to  the  amount  of  narrow- 
ing of  the  walls,  and  to  their  smoothness  or  roughness. 
The  murmurs  are  transmitted  most  easily  in  the  direction 
of  the  blood  current  which  causes  them  ;  therefore,  in 
mitral  insufficiency,  a  systolic  murmur  is  heard  most 
distinctly  at  the  second  costal  cartilage  of  the  left  side, 
where  the  enlarged  left  auricular  appendix  lies  near  the 
pulmonary  artery,  close  to  the  chest-wall. 

A  systolic  murmur  of  the  mitral  and  tricuspid  valves  is 
indicative  of  an  insufficiency  of  these  valves,  and  a  mur- 
mur at  the  aortic  and  pulmonary  valves,  indicates  a 
stenosis  of  these  valves. 

A  diastolic  murmur  at  the  mitral  and  tricuspid  valves 
is  a  sign  of  stenosis  of  these  valves,  and  a  diastolic  mur- 
mur at  the  aortic  and  pulmonary  means  an  insufficiency 
of  these  valves.  Diastolic  murmurs  are  generally  of 
greater  diagnostic  importance  than  systolic  murmurs, 
and  we  therefore  lay  more  stress  upon  these,  in  the 
study  of  valvular  affections. 

In  heart  murmurs,  we  make  a  distinction  between 
pericardial  and  endocardial  murmurs,  and  we  divide  the 
endocardial  again  into  organic,  and  accidental  or  inor- 
ganic. The  accidental  murmurs  are  generally  soft  and 
blowing,  and  most  frequently  systolic,  and  very  seldom 
diastolic.  They  are  observed  in  faulty  nutrition,  and  in 
contraction  of  the  heart  musculature  in  high  fever  and  in 
changes  in  the  blood  (anaemia,  chlorosis,  hydrsemia). 
In  progressive  pernicious  ansemia,  and  bad  cases  of 
chlorosis,  accidental  diastolic  murmurs  are  also  heard. 

Pericardial  friction  murmurs  are  caused  by  roughness 
of  the  pericardium,  as  in  deposits  of  fibrin,  tubercle,  and 
carcinoma,  pericarditis,  and  abnormal  dryness  of  the 
pericardium.     They   are  generally   slight  rubbing,  jerk- 


48  CLINICAL   DIAGNOSIS. 

ing  sounds,  and  seem  very  near  the  ear.  They  are  not 
always  synchronous  with  the  systole  or  diastole,  but  are 
often  between  both.  They  are  influenced  in  their  in- 
tensity by  change  of  position,  and  by  deep  inspiration. 
The  normal  heart  sounds,  or  endocardial  murmurs,  may 
occur  with  them. 

Extraperica7'dial friction  sounds,  caused  by  friction  be- 
tween the  pericardium  and  the  pleura,  are  dependent 
upon  the  respiratory  movements  of  the  lungs  as  well  as 
upon  the  heart's  action.  They  generally  cease  on  hold- 
ing the  breath. 

Auscultation  of  the  Blood  Vessels. 

Over  the  carotid  and  subclavian  two  sounds  are 
heard  with  each  movement  of  the  heart.  The  first,  cor- 
responds to  the  systole  of  the  heart  and  expansion  (dia- 
stole) of  the  arteries  ;  the  second,  to  the  diastole  of  the 
heart  (closure  of  the  aortic  valve)  and  to  contraction 
(systole)  of  the  arteries.  The  first  tone  arises  from  dis- 
tension of  the  arterial  wall,  the  second  is  the  sound,  of 
the  aortic  valves  transmitted  along  the  vessels.  The 
second  sound  is  absent  at  the  aorta  and  subclavian  in  in- 
sufficiency of  the  aortic  valves.  In  stenosis  of  the  aortic 
and  sometimes  in  insufficiency  of  the  aortic  and  mitral 
valves,  in  atheroma  of  the  aorta,  in  fever,  etc.,  there  is 
heard  over  the  carotid  a  murmur  which  is  synchronous 
with  the  systole  of  the  heart  and  is  called  an  arterial  dia- 
stolic murmur. 

/;/  the  more  distant  arteries  (crural,  brachial,  radial)  no 
sounds  or  murmurs  are  normally  heard.  On  pressure, 
however,  with  the  stethoscope  upon  the  vessel,  there  is 
heard  an  arterial  diastolic  murmur,  and  bv  still  harder 
pressure,  there   is   a    sound  called    pressure-tone    heard. 


CIRCULATORY  SYSTEM.  49 

Abnormal  sounds  in  the  small  arteries  (cubital,  palmar, 
etc.),  are  heard  in  aortic  insufficiency  ;  arterial  murmurs 
are  heard  in  insufficiency  of  the  aortic  valve  and  in 
aneurisms.  A  double  sound  is  heard  over  the  crural  artery 
in  aortic  insufficiency,  in  lead  poisoning,  and  pregnancy. 

We  auscultate  the  carotid  at  the  point  of  insertion  of  the  sterno- 
mastoid  muscle  into  the  clavicle  and  sternum,  or  at  the  inner  border 
of  this  muscle,  on  a  level  with  the  thyroid  cartilage.  We  auscultate 
the  subclavian  in  the  groove  of  Mohrenheim,  or  at  the  outer  part  of 
the  supraclavicular  fossa. 

The  cubital  and  crural  arteries  are  auscultated  respectively  in  the 
bend  of  the  arm  and  in  the  popliteal  space.  The  stethoscope  should 
not  be  pressed  down  at  all. 

In  small  children  from  three  months  on,  to  the  time 
when  the  greater  fontanelle  closes,  a  systolic  blowing 
murmur  may  be  heard  at  that  point. 

A  placental  murmur  is  heard  in  the  second  half  of 
pregnancy. 

When  the  jugular  vein  is  partly  distended  (in  all  forms 
of  anaemia,  especially  in  chlorosis),  a  whistling,  continu- 
ous murmur  (bruit  de  diable)  is  heard  over  this  vein,  at 
the  outer  border  of  the  sterno-mastoid  muscle.  This  mur- 
mur is  increased  in  intensity  when  the  head  is  turned  to 
the  other  side.  In  severe  cases  of  anaemia,  a  murmur  is 
also  heard  over  the  crural  vein. 


CHAPTER  VII. 
THE    PULSE. 

The  following  varieties  of  pulse  are  distinguished. 

(i)  The  frequency  of  the  pulse  in  healthy  adults  is  on 
an  average  of  70  beats  a  minute  (60-80),  in  children 
100-140,  and  in  old  men  70-90,  sometimes  more. 

The  slower  moveinent  of  the  pulse  (pulsus  rarus)  is  observed  in 
icterus  (from  the  effect  of  the  gall  acids  on  the  heart  ganglia),  in  irri- 
tation of  the  vagus,  in  paralysis  of  the  heart  ganglia  and  of  the  cer- 
vical s}Tnpathetic,  in  increased  cranial  pressure  (first  stage  of  basilar 
meningitis),  in  anaemia,  in  many  diseased  conditions  of  the  heart 
musculature  (fatty  heart),  and  in  stenosis  of  the  aortic  valves. 

Acceleration  of  the  pulse  (pulsus  frequens)  is  observed  normally  on 
muscular  exertion  (to  140),  at  times  in  weakened  individuals,  and 
after  taking  food,  and  pathologically  in  fever,  so  that  for  every  1° 
[i.S°  F.]  of  increased  temperature,  there  are  about  8  pulse  beats  ; 
further,  in  paralysis  of  the  vagus,  and  in  excessively  increased  cere- 
bral pressure  (in  the  last  stage  of  basilar  meningitis),  in  many  neuroses 
of  the  heart  (stenocardia,  morbus  Basedowii,  etc.),  in  acute  disease  of 
the  heart  (endocarditis,  pericarditis,  and  many  cases  of  myocarditis), 
in  almost  all  valvular  troubles  when  there  is  disturbed  compensation, 
and  in  collapse. 

(2)  Rhythm  (Pulsus  regularis  and  irregularis). 

Irregular,  arhythmic  pulse  is  observed  in  extreme  old  age,  and  in 
many  diseases  of  the  heart  and  brain.  An  irregular  pulse  is  of  minor 
importance  in  advanced  age,  whereas  in  childhood  it  is  observed  in 
severe  diseases  only,  as  in  basilar  meningitis.  By  pulsus  alternans  is 
understood  that  kind  of  pulse  in  which  a  low  pulse  wave  follows  a 
high  one.  By  pulsus  bigeminus  and  trigetnimis  is  understood  a  pulse 
in  which  there  is  a  long  pause  after  every  two  or  three  beats.     Pulsus 

50 


THE  PULSE.  51 

paradoxus  occurs  when  the  pulse  is  smaller  with  each  inspiration  or 
may  even  entirely  disappear,  as  in  inflammation  of  the  mediastinum, 
pericardial  adhesions,  and  stenosis  of  the  air  passages.  Retardation  or 
unequal  size  of  the  pulse,  is  where  tiiere  is  a  difference  between  the 
radial  pulse  of  both  sides,  or  between  the  upper  and  lower  half  of  the 
body,  and  is  observed  principally  in  aneurism  and  narrowing  of  the 
arteries. 

(3)  Quickness  (pulsus  celer  or  tardus,  fast  or  slow 
pulse),  /.  e.^  the  quickness  with  which  the  arteries  dis- 
tend and  contract.  The  sphygmographic  curve  of  the 
pulsus  celer  is  steep  and  pointed,  that  of  the  pulsus 
tardus,  long  and  shallow  ;  the  tracing  shows  a  rounded 
top  to  the  pulse  wave. 

Pulsus  celer  is  observed  in  strengthened  heart  action,  and  in  hyper- 
trophy of  the  left  ventricle,  as,  for  example,  in  Basedow's  disease  and 
in  granular  nephritis,  and  is  most  marked  in  i7isttfficiency  of  the  aortic 
valves  (Fig.  21,  No.  VIII.).  Piilstis  tardus  is  observed  in  extreme 
old  age  {senile  pulse,  with  rounded  top.  Fig.  20,  No.  II.),  and  in 
aortic  stenosis.  (Here  the  tracing  shows  a  wave  whose  course  is 
long  drawn  out.) 

(4)  Size  (pulsus  magnus  or  parvus),  that  is,  the  height 
of  the  pulse  wave.  The  pulse  is  larger  in  proportion  to 
the  impelling  power  of  the  heart,  and  to  the  amount  of 
blood  drawn  into  the  arteries,  and  the  less  their  tension 
is.  A  large  pulse  is  observed  in  aortic  insufficiency,  in 
cardiac  hypertrophy,  in  fever  ;  and  a  small  pulse  in 
stenosis  of  the  cardiac  openings,  in  cardiac  weakness, 
and  in  chill. 

(5)  Fulness- {^vX'iM'i,  plenus  or  vacuus),  /.  e.^  when  the 
arteries  are  partly  filled  only,  and  a  pulsus  plenus  is  ob- 
served in  increased  impelling  power  of  the  heart,  and 
when  the  contractibility  and  elasticity  of  the  arterial 
system   remain  the  same,  or  in  hypertrophy  of  the  left 


52 


CLINICAL  DIAGNOSIS. 


ventricle  ;  pulsus  vacuus  is  observed  when  the  arterial 
system  is  only  partly  filled  with  blood. 

(6)  Ha7'dness  (pulsus  durus  or  mollis),  i.  e.,  the  de- 
gree of  tension  in  the  arterial  system  in  proportion  to  the 
resistance  felt  to  the  finger.  A  hard  pulse  is  difficult  to 
suppress.  A  hard  wiry  pulse  is  observed  in  increased  im- 
pelling power  of  the  heart  (hypertrophy  of  the  left  ven- 
tricle), as  well  as  in  a  spasm  of  the  arterial  muscle  (lead 
colic).  A  soft  pulse  is  felt  in  mitral  troubles,  in  fever, 
and  anaemia.  An  apparently  hard  pulse  is  observed  in 
atheroma  of  the  arteries. 

When  the  pulse  curve  is  traced  with  a  sphyginograph, 
we  notice  an  ascending  and  a  descending  line.     Eleva- 

Fig.  20. 


I. 

II. 

III. 

IV. 

V. 

VI. 

Normal  pulse. 

Senile  pulse. 
Pulsus  tardus. 

Subdicrotic. 

Dicrotic. 

Hyperdicrotic. 

Monocrotic, 

Fig.  21. 


tions  on  the  ascending  part  are  called  anacrotic,  on  the 
descending,  catacrotic.  According  to  the  number  of 
catacrotic    elevations,    a    pulse    is    called    catadicrotic, 

catatricrotic,  etc. 
In  the  normal  pulse  ^ 
the  ascending  arm 
of  the  curve  is 
straight,  while  the 
descending  a  r  m 
shows  certain  ele- 
vations due  to  the 
elasticity  of  the  arterial  wall  (the  elevation  of  recoil^  Fig.  20, 
No.  I.,  ^),  and  a  greater  elevation  due  to  the  recoil  of  the 
column  of  blood  on  the  aortic  valves,  and  one  or  more 


Pulse  of  tension.     P.  magnus  etceler. 
Lead  colic.      Aortic  insufficiency. 


P.  parvus,  irregu- 
laris.    Mitral 
affections. 


THE  PULSE.  53 

smaller  elevations  due  to  the  vibration  in  the  tense  elastic 
arterial  wall.  (Fig.  20,  No.  I.,  a  and  c).  The  greater 
the  arterial  tension,  the  more  are  these  elevations  of 
elasticity,  and  the  more  distinct  is  the  elevation  due 
to  the  recoil  (lead  colic,  Fig.  21,  No.  VII.,  acute  and 
chronic  nephritis).  If  the  arterial  tension  decreases,  the 
elevation  of  elasticity  disappears,  and  the  elevation  of 
recoil  becomes  greater  and  is  nearer  the  beginning  of  the 
curve.  It  may  be  felt  as  a  recoil  wave,  and  in  this  case 
the  pulse  is  said  to  be  dicrotic. 

A  dicrotic  ptdse  is  observed  principally  in  fever,  so  that 
with  increasing  fever  and  decreasing  arterial  tension,  the 
pulse  becomes  first  subdicrotic  (HI.),  then  dicrotic  (IV.), 
hyperdicrotic  (V.),  and  finally,  with  extremely  high  tem- 
perature, it  is  monocrotic  (VI.).  With  a  subdicrotic  pulse, 
the  elevation  of  recoil  appears  before  the  descending  line 
has  reached  the  base  of  the  curve  ;  in  complete  dicrotic 
pulse,  after  it  has  reached  the  base  of  the  curve  ;  in 
hyperdicrotic  pulse,  the  elevation  of  recoil  belongs  to 
the  ascending  part  of  the  next  wave  ;  and  in  monocrotic 
pulse,  no  elevation  of  recoil  can  be  recognized. 

A  slow  ascending  line,  round  and  broad  top,  no  eleva- 
tion of  elasticity,  and  a  slight  recoil,  are  observed  in 
atheroma  of  the  aorta  (pulsus  tardus,  senile  pulse).  A 
slight  elevation  and  long  line  of  descent  is  observed  in 
stenosis  of  the  aortic  valves.  Anacrotic  elevations  in  the 
ascending  branch  of  the  curve  (Fig.  20,  II.)  occur  in  dis- 
eases of  the  arterial  wall  or  aortic  valves,  by  the  disten- 
sion of  the  arteries  being  slow  and  jerky. 

'Y\iQ  pulse  curve  in  the  veins  is  the  reverse  of  that  in  the 
arteries.  This  ascends  slowly  and  falls  quickly.  The 
ascending  branch  of  the  curve  is  anadicrotic,  the  second 
elevation  coming  from  the  contraction  of  the  right  auricle, 


54'  CLINICAL   DIAGNOSIS. 

The  venous  pulse  observed  in  insufficiency  of  the  tricus- 
pidy  is  characterized  by  its  beginning  in  the  diastole, 
reaching  its  7naxi7num  in  the  systole,  and  continuing  through 
the  same.  The  venous  pulse,  however^  occurring  with  a 
normal  tricuspid  valve,  falls  immediately  before  the 
beginning  of  the  systole,  /.  <?.,  before  the  ascent  of  the 
arterial  blood  wave.  To  be  convinced  of  this  it  is  only 
necessary  to  put  the  finger  on  the  carotid  and  follow  the 
venous  pulse  with  the  eye.  The  wave  appearing  in  tri- 
cuspid insufficiency,  and  outlasting  the  arterial  pulse, 
comes  from  the  blood  wave,  which  is  thrown  back  during 
the  systole  through  its  insufficient  valve  into  the  auricle 
and  upon  the  venous  system. 


CHAPTER  VIII. 
DIGESTIVE  AND  ABDOMINAL  ORGANS. 

The   Teeth. 

The  milk  teeth  are  twenty  in  number,  namely,  2  inci- 
sors, I  canine,  and  2  bicuspids  on  each  side  of  each  jaw. 
The  milk  teeth  come  through  between  the  7th  month  and 
the  end  of  the  2d  year.  The  first  to  appear  is  the  middle 
inferior  incisor  in  the  6th-8th  month.  Then  follow 
the  remaining  six  in  the  7th-9th  month.  Then  come 
the  upper  and  lower  anterior  bicuspids  in  the  I2th-i5th 
month,  and  at  the  end  of  the  second  year  appear  the 
posterior  molars.  In  the  yth  y;  r  the  2d  dentition  be- 
gins, and  the  milk  teeth  fall  out  in  about  the  same  order 
in  which  they  came. 

The  permanent  teeth  are  32  in  number,  namely,  2  inci- 
sors, I  canine,  2  bicuspids,  3  molar  on  each  side  of  each 
jaw.  First  appears  the  anterior  molar,  which  comes 
through  behind  the  temporary  bicuspid  in  the  4th-5th 
year.  In  the  7th  year,  the  central  incisors  follow  ;  in  the 
8th  year,  the  external  incisors,  i.  e.,  first  the  lower  and 
then  the  upper.  In  9th-ioth  year,  the  anterior  bicuspid 
appears  ;  in  the  loth-iith  year,  the  canine  ;  in  the  iith- 
i2th  year,  the  posterior  bicuspid.  The  second  (middle) 
tricuspid  appears  between  the  12th- 13th  year;  the  pos- 
terior tricuspids,  or  wisdom  teeth,  between  the  i6th  and 
30th  year. 

55 


56  CLINICAL   DIAGNOSIS. 

The  Saliva. 

The  normal  saliva  has  a  specific  gravity  of  1002  to 
1006  ;  the  normal  reaction  is  alkaline,  but  it  is  often 
made  acid  by  decomposition  in  the  mouth,  as,  for  exam- 
ple, in  diabetes  mellitus.  The  saliva  contains  only  traces 
of  albumen,  and  sometimes,  but  not  always,  sulphocyan- 
ide  of  potassium  (SCNK).  This  may  be  recognized  by 
adding  a  few  drops  of  hydrochloric  acid,  and  a  diluted 
solution  of  chloride  of  iron,  when  a  blood-red  color  is 
formed,  which  is  taken  up  on  shaking  with  ether.  In 
the  saliva  there  is  also  a  diastatic  ferment,  which  may  be 
shown  by  adding  to  a  test-tube  of  saliva  a  diluted  starch 
paste,  and  letting  it  stand  at  the  temperature  of  the  body. 
In  a  few  minutes  sugar  is  formed  which  may  be  shown 
by  Trommer's  test. 

CEsophagus. 

The  length  of  the  oesophagus  is,  in  adults,  on  an  aver- 
age 25  cm.  [8|-  inches]  ;  8  cm.  [31  inches]  below  its  be- 
ginning, it  is  crossed  by  the  bronchus.  The  distance 
from  the  upper  incisors  to  the  beginning  of  the  oesopha- 
gus is  about  15  cm.  [6  inches].  Accordingly,  when  the 
oesophageal  sound  passes  the  distance  of  40  cm.  [15I 
inches],  counting  from  the  upper  incisor,  we  know  it  is 
in  the  stomach,  and  if  after  23  cm.  [9  inches]  it  comes 
upon  an  obstruction,  we  may  infer  that  there  is  a  steno- 
sis or  diverticulum  at  the  point  where  the  bronchus 
crosses  the  oesophagus.  If  the  sound  penetrate  60-70 
cm.  [25I— 27I-  inches]  and  its  point  can  be  felt  through 
the  abdominal  walls  below  a  line  drawn  through  the  an- 
terior superior  spine  of  the  ilium,  then  there  is  disten- 
sion of  the  stomach. 

On  ausciUtating  the  oesophagus  just  to  the  left  of  the 


DIGESTIVE  AND  ABDOMINAL   ORGANS.  t^'J 

vertebral  column,  there  is  heard  a  short  murmur  just  af- 
ter swallowing,  and  this  murmur  in  stenosis  may  be  de- 
layed, weakened,  or  may  even  disappear.  On  ausculta- 
tion in  the  epigastric  fossa  (or  still  better,  at  the  angle 
behind  the  left  costal  curvature  and  the  ensiform  carti- 
lage) there  is  heard,  generally  immediately  after  swallow- 
ing, a  short  murmur,  or  a  few  seconds  later,  a  longer 
murmur  (the  murmur  of  Kronecker  and  Meltzer  and  the 
primary  and  secondary  murmur  of  Ewald). 

Stomach. 

Five  sixths  of  the  stomach  are  to  the  left  and  one.  sixth 
to  the  right  of  the  median  line.  The  fundus  lies  under  the 
left  leaflet  of  the  diaphragm.  The  lesser  curvature  of 
the  stomach  and  the  pylorus  are  covered  by  the  left  lobe 
of  the  liver.  The  pylorus  lies  in  the  right  sternal  line 
about  at  the  height  of  the  tip  of  the  ensiform  cartilage. 
The  greater  curvature  takes  a  course  about  2-4  cm.  [i 
inch]  above  the  umbilicus. 

In  order  to  mark  out  the  stomach  by  pei-ciission,  we 
must  first  determine  the  position  of  the  diaphragm,  and 
the  borders  of  the  liver  and  spleen  dulness.  Between 
these  organs  we  come  upon  the  deep  tympanitic  sound 
of  the  stomach,  which  may  be  more  or  less  easily  distin- 
guished from  the  high  tympanitic  percussion  note  of 
the  intestines.  The  half -moon  shaped  space  of  Traube  is 
the  upper  part  of  this  tympanitic  space,  which  lies  be- 
tween the  lungs  on  one  side,  and  liver  and  spleen  on  the 
other.  Fuller  particulars  as  to  the  size  of  the  stomach, 
are  obtained  by  artificially  distending  the  same  with 
carbonic  acid  gas.  This  is  done  by  administering  a 
teaspoonful  of  bicarbonate  of  soda  and  tartaric  acid,  as 
separate  doses,   in  water.     When  the  stomach  is  partly 


5 8  CLINICAL  DIAGNOSIS. 

filled  with  food,  there  is  found,  on  percussion  in  the 
lower  part,  a  dulness,  which  changes  its  position  with 
the  movements  of  the  patient.  The  stomach  is  consid- 
ered dilated,  when  the  greater  curvature  reaches  below 
the  umbilical  line.  There  is  also  a  splashing  noise  heard 
on  shaking  the  patient. 

In  palpation,  attention  should  be  directed  to  circum- 
scribed parts  which  are  painful  on  pressure.  They  may 
point  to  an  ulcer  or  tumor  (carcinoma).  Tumors  of  the 
stomach,  in  distinction  from  those  of  the  liver,  do  not 
move  vertically  during  respiration. 

Examination  of  the  Stomach's  Contents. 

Under  normal  conditions,  the  stomach  digestion  of  a 
moderately  hearty  meal  is  over  in  6-7  hours  and  the 
stomach  is  again  empty.  If,  after  this  time,  lavage  of 
the  stomach  shows  large  quantities  of  food  debris,  it 
must  be  considered  as  a  sign  of  disturbed  digestion. 

To  accurately  define  the  digesting  strength  of  the 
stomach,  and  the  amount  of  acid  the  gastric  juice  con- 
tains, a  sample  of  the  digestive  mixture  ^  is  drawn  off 
with  a  stomach  sound  two  hours  after  eating. 

Test  of  the  Amount  of  Acid  Contained. — The  reaction  is  first 
tested  with  litmus  paper.  An  acid  reaction  may  be  caused  by  hy- 
drochloric acid,  or  by  the  organic  acids  (lactic,  butyric,  acetic).  To 
test  for  hydrochloric  acid,  a  few  drops  of  a  diluted  water)'  solution  of 
methylviolet  or  trop^oline  are  added  to  a  few  drops  of  filtered  gastric 
juice.  Even  0.1-0.2  ^^  of  hydrochloric  acid  causes  a  distinct  colored 
precipitate  of  blue  or  reddish  brown,  while  a  much  greater  concentra- 
tion is  required  to  produce  the  same  precipitate  in  the  case  of  the 


^  According  to  Leube,  the  gastric-juice  secretion  is  excited  by 
pouring  lOO  ccm.  [6  ounces]  of  ice-water  into  the  stomach  after  it 
has  been  washed  out  with  tepid  water,  and.  ten  minutes  later  syphon- 
ing off  a  sample. 


DIGESTIVE   AND   ABDOMINAL    ORGANS.  59 

other  acids.  To  test  for  lactic  acid,  a  few  drops  of  the  filtered  gastric 
juice  are  added  drop  by  drop  to  1-2  drops  of  a  reagent  consisting  of 
3  drops  of  the  solution  of  the  sesquichloride  of  iron,  10  cm.  [2^ 
drachms]  of  a  4  ^^  carbolic-acid  solution,  and  20  cm.  [5  drachms]  of 
water.  The  original  amethyst  blue  is  turned  yellow  by  lactic  acid, 
and  pale  gray  by  hydrochloric  acid  and  butyric  acid  (Uffelmann). 
When  lactic  and  hydrochloric  acids  are  both  present,  the  former  is 
removed  with  ether,  and  the  residue  is  tested  for  the  latter.  iVll 
these  tests  are  not  very  reliable,  and  are  influenced  by  the  degree  of 
the  acidity  and  the  presence  of  such  bodies  as  the  peptones,  neutral 
salts,  etc.,  preventing  the  reaction.  Still,  it  can  generally  be  pre- 
sumed that  when  the  reaction  shows  a  large  amount  of  hydrochloric 
acid  present,  a  carcinoma  of  the  stomach  is  probably  to  be  excluded. 
In  order  to  test  the  digesting  strength  of  the  gastric  juice,  to  two 
test-tubes  containing  gastric  juice  a  bit  of  washed  fibrin,  and  to  one 
of  these  test-tubes  a  few  drops  of  i  ^c  hydrochloric  acid,  are  added, 
and  both  tubes  are  put  into  the  incubator  at  body  temperature.  If 
after  6-12  hours  the  fibrin  in  neither  tube  is  dissolved,  there  is  evi- 
dently want  of  pepsin  in  the  sample,  and  if  the  fibrin  in  the  gastric 
juice  containing  the  i  f«  hydrochloric  acid  is  alone  digested,  then  we 
surmise  that  this  gastric  juice  contains  pepsin,  but  no  hydrochloric 
acid.  When  the  gastric  juice  is  normal,  the  fibrin  in  both  tubes 
should  disappear  in  1-2  hours. 

Vomited  matter  may  contain  : 

Mucus  (in  gastric  catarrh)^ 

Swallowed  saliva  (in  the  morning  sickness  of  drunk- 
ards). This  may  be  recognized  by  its  containing  ferro- 
cyanide  of  potash  (showing  a  blood-red  color  on  addition 
of  a  solution  of  chloride  of  iron). 

Blood  (ulcer  and  carcinoma  of  the  stomach,  cirrhosis 
of  the  liver).  This  may  be  either  unchanged,  or  is  di- 
gested to  a  brown,  coffee-ground  mass,  due  to  its  long 
stay  in  the  stomach.  In  this  latter  case,  the  red  blood- 
corpuscles  are  dissolved,  and  the  haemoglobin  changed 
to  hsematin,  which  may  be  shown  with  the  hcemin  test 
{ind.  page  i). 


6o  CLINICAL   niAGXOSlS. 

Gall  is  also  found  when  the  vomiting  is  frequent  and 
of  long  duration.  In  uraemia,  ttrea  and  carbonate  of  aj?i- 
monia  are  found  in  the  vomitus. 

Remains  of  food,  which  may  be  more  or  less  altered, 
either  by  the  process  of  digestion  or  by  micro-organisms. 
The  effects  of  the  latter  causing  fermentation  and  de- 
composition, form  lactic,  butyric,  and  acetic  acids  out 
of  the  carbohydrates  (starch  and  sugar)  ;  free  fatty  acids 
out  of  the  neutral  fats  ;  peptones,  leucin,  tyrosin,  phenol- 
indol,  skatol,  sulphuretted  hydrogen,  and  ammonia  out 
of  the  albuminous  substances.  These  latter  are  products 
of  advanced  decomposition,  and  are  found  principally 
when  the  contents  of  the  small  intestines  regurgitate  into 
the  stomach  and  are  vomited  (vomiting  of  fseces). 

On  microscopical  examination  of  the  vomitus,  there  are 
found  apart  from  the  remains  of  food  (cross-striped 
muscular  fibres,  fat,  starch,  vegetable  substances,  etc.) 
pavement  epithelium  of  the  mouth  and  oesophagus,  and 
more  seldom  cylindrical  epithelium  of  the  stomach,  as  con- 
stant leucocytes,  schizomycites  of  the  most  varied  kind  ; 
sometimes  yeast-cells,  sarcinse,  and  oidium  albicans. 

Liver. 

The  upper  border  of  the  liver  dubiess  begins  at  the 
lower  border  of  the  right  lung  and  of  the  heart.  The 
lower  border  is,  in  healthy  individuals,  in  the  axillary 
line  between  the  tenth  and  eleventh  ribs,  at  the  curvature 
of  the  ribs  in  the  mammary  line  ;  and  at  the  median  line 
it  lies  between  the  xiphoid  process  and  the  umbilicus  ;  it 
then  takes  a  curved  direction  upwards  and  reaches  the 
diaphragm  and  generally  the  heart  apex  between  the 
parasternal  and  mammary  line.  In  deep  inspiration, 
when  the  patient  lies  on  the  left  side,  the  liver  dulness 


DIGESTIVE  AND  ABDOMINAL    ORGANS.         6l 

is  smaller,  because  the  lung  border  comes  down  further. 
The  lower  border  of  the  liver  moves  up  and  down  slightly 
during  respiration. 

The  liver  \%  forced  down  in  emphysema,  pneumothorax,  pleurisy, 
and  pericardial  exudations. 

It  is  pushed  upwards  in  contraction  of  the  right  lung  and  in 
increased  pressure  from  below  in  the  abdominal  cavity,  as  in  peri- 
tonitis, ascites,  tumors,  and  pregnancy.  From  this  cause  the  anterior 
edge  of  the  liver  may  be  turned  up,  causing  a  material  decrease  in  the 
size  of  the  liver-dulness. 

Hypertrophy  of  the  liver  occurs  in  the  first  stage  of  cirrhosis, 
in  congestion,  in  fatty  and  waxy  liver.  Decrease  in  the  size  of 
the  liver-dulness  occurs  in  atrophic  nutmeg  liver,  acute  yellow  atro- 
phy, in  the  second  stage  of  cirrhosis,  and  when  the  transverse  colon 
lies  between  the  abdominal  wall  and  the  liver.  AYhen  air  enters  the 
peritoneal  cavity,  there  is  complete  absence  of  liver-dulness  in  the 
median  line. 

In  healthy  adults  the  surface  and  edge  of  the  liver  cannot  be  felt. 
It  is,  however,  resistent  and  to  be  felt  in  congestion,  cirrhosis,  amy- 
loid degeneration,  multilocular  echinococcus,  and  not  so  easy  to  be 
felt  in  fatty  liver.  Inequalities  of  the  liver-surface  and  tumors  may 
be  easily  felt  in  cirrhosis,  syphilis  of  the  liver,  abscess,  carcinoma, 
and  echinococcus.  When  the  echinococcus  cysts  are  present  there  is 
a  slight  fluctuation  to  be  felt  over  the  liver  (hydatid  purring). 

In  the  liver  of  tight  lacing  that  part  of  the  right  lobe  is  felt  as 
a  round  tumor  below  the  ribs  and  separated  from  the  rest  of  the  liver 
by  a  horizontal  furrow.  In  wandering  liver,  the  organ  is  dislocated 
downwards  (also  in  the  upright  position)  and  abnormally  movable. 

The  enlarged  gall  bladder  C3.n  sometimes  be  percussed  about  5  cm. 
[2  inches]  to  the  right  of  the  median  line  at  the  lower  border  of  the 
liver  and  can  be  felt  as  a  round  tumor. 

The  Spleen. 

The  normal  splenic  dulness  is  in  the  left  hypochon- 
drium,  between  the  ninth  and  eleventh  ribs  and  reaches 
forward  to  the  costo-articular  line  (drawn  from  the  left 
sterno-clavicular  articulation  to  the  tip  of  the  eleventh 


62  CLINICAL   DIAGNOSIS. 

rib)  and  backward  to  the  spinal  column.  The  height 
(breadth)  of  the  spleen-dulness  is,  in  the  middle  axillary 
line,  5-6  cm.  (2-2 1  inches).  On  inspiration  and  when  ly- 
ing on  the  right  side,  the  splenic  dulness  is  made  smaller 
by  the  lower  border  of  the  left  lung  moving  down. 

The  spleen  is  lower  down  in  a  pleural  exudation  of  the  left  side, 
in  pneumothorax,  and  emphysema.  In  ascites,  tympanites,  tumors 
of  the  abdomen,  the  spleen  is  pressed  upward  against  the  diaphragm 
and  the  dulness  is  made  smaller. 

Hype^'trophy  of  the  spleen  is  observed  in  almost  all  infectious 
diseases  (t}^hoid  fever,  typhus,  pyaemia,  the  acute  exanthematous 
diseases,  beginning  secondary  syphilis,  in  many  forms  of  pneu- 
monia, etc.)  ;  further  in  leucgemia,  amyloid  degeneration,  cirrhosis 
of  the  liver,  haemorrhagic  infarct  of  the  spleen,  echinococcus,  and  in 
the  severer  forms  of  intermittent  fever.  When  the  spleen  is  greatly 
hypertrophied  the  end  may  be  felt  under  the  left  border  of  the  ribs. 

An  appa7-ent  hypertrophy  is  obsen-ed  in  pleural  exudations  of  the 
left  side  and  in  infiltration  of  the  left  lung. 

The  splejiic  dulness  is  absent  in  wandering  spleen  and  on  the  pres- 
ence of  air  in  the  peritoneum  when  the  patient  lies  on  the  right 
side. 

In  situs  viscertim  transversus  the  splenic  dulness  is  on  the  right 
side  and  the  hepatic  dulness  on  the  left  side. 

Abdomen. 

The  abdomen  emits  under  normal  circumstances  a 
tympanitic  sound  of  varying  height  in  all  parts. 

A  sinking  in  of  the  abdomen  is  observed  when  the  intes- 
tines are  empty  and  contracted  (in  inanition,  meningitis, 
lead  colic). 

Distention  of  the  abdominal  walls  occurs  in  overloading 
of  the  stomach  and  intestines  with  air  (tympanites)  or 
fluid,  in  collections  of  air  or  fluid  in  the  peritoneum  and 
intestines. 

In  collection  of  free  fluid  in  the  peritoneum,  ascites 


DIGESTIVE  AND  ABDOMINAL   ORGANS.         63 

(in  heart  disease  and  congestion  of  the  portal  system, 
especially  cirrhosis  of  the  liver)  the  abdomen  is  laterally 
distended,  and  in  the  middle,  flat  when  the  patient  is 
recumbent.  The  fluid,  which  may  be  found  by  dulness 
and  fluctuation,  shows  a  horizontalboundary  line  above 
when  the  patient  stands,  and  changes  its  position  quickly 
when  the  patient  moves  about. 

In  inflammatory  exudations  of  the  peritoneum,  the  abdomen  is 
generally  equally  distended,  and  the  fluid  is  often  encysted  and  im- 
movable. If  the  fluid  is  very  great  in  amount  the  intestines  do  not 
reach  the  abdominal  wall  (also  when  the  mesentery  is  shorter)  and 
there  is  everywhere  dulness  on  percussion. 

When  air  enters  the  peritoneum,  it  always  seeks  the  highest  level 
and  causes  the  liver-dulness,  i.  e.,  its  central  part,  or  the  splenic  dul- 
ness, to  disappear,  according  to  the  position  of  the  patient.  In 
tumors  there  is,  according  to  the  position,  an  unequar distention  of 
the  abdomen,  e.  g.,  in  tumors  of  the  liver  and  spleen  there  is  a  dis- 
tention in  the  upper  part  of  the  abdomen,  and  in  uterine  and  ovarian 
tumors  in  the  middle  and  lower  parts. 

In  peritonitis  there  is  occasionally  a  friction  sound  to  be  felt  and 
heard. 

Addendum. 


The  Faeces. 

The  faeces  consist  of 

(i)  The  remains  of  the  food  altered  by  the  processes 
of  digestion  and  decomposition. 

(2)  The  digestive  juices  in  the  intestines,  and 

{3)  Certain  products  of  excretion  which  come  from 
the  body  through  the  glands  opening  into  the  intestines, 
e.  g.,  the  salts  of  the  heavy  metals,  iron,  lead,  mer- 
cury, etc. 

As  to  the  consiste?ice  we  distinguish  j^rz??,  thick  fluid ^  thin 
fluids  and  watery.    The  two  last  kinds  are  not  considered 


64  CLINICAL  DIAGNOSIS. 

normal  unless  they  are  caused  by  the  diet  or  by  purga- 
tives. Watery  passages  (diarrhoea)  appear  when  the  food 
passes  through  the  intestines  so  quickly  that  the  absorp- 
tion is  incomplete,  or,  more  rarely,  when  there  is  an  exu- 
dation into  the  intestines,  as  in  dysentery. 

Mucus  may  form  a  glassy  covering  to  the  fasces,  or  be 
mixed  in  large  coarse  lumps  with  it  (in  affections  of  the 
large  intestine,  even  in  its  lower  parts),  or  it  is  intimate- 
ly mixed  in  small  particles  with  the  faeces  (in  disease  of 
the  upper  part  of  the  large  or  small  intestine).'  If  the 
mucus  is  colored  with  gall,  or  if  it  reacts  with  the  test  of 
Gmelin,  we  may  consider  that  the  small  intestine  is  af- 
fected. Purulent  mucus  is  observed  in  ulceration  of  the 
intestines.  Large  cylindrical  masses  of  mucus  are  passed 
in  the  so-called  mucous  colic  (Nothnagel). 

The  color  of  the  fasces  is  caused  principally  by  the 
coloring  substance  of  the  gall.  Generally  the  coloring 
substance  is  altered  by  bacteria  and  reduced  to  hy- 
drobilirubin,  but  sometimes  the  coloring  substance  of 
the  gall  appears  unchanged,  as  in  the  yellow  and  green 
passages  of  infants,  and  when  the  peristalsis  is  especially 
rapid. 

If  the  gall  be  absent  in  the  intestine  (as  in  icterus)  the 
passage  contains  abundant  fat,  and  appears  therefore 
gray,  greasy,  and  clayey,  and  on  shaking  with  water 
there  is  a  peculiar  play  of  colors  noticed.  The  passages 
show  an  abundant  amount  of  fat  and  a  similar  appearance 
when  the  absorption  of  fat  does  not  take  place  on  ac- 
count of  various  diseases  of  the  intestinal  mucous  mem- 
brane or  of  the  chylopoetic  system. 

The  color,  as  well  as  the  consistence  and  amount,  of  the 
faeces  is  also  dependent  upon  the  food  taken.  In  an 
almost  exclusively  vieat  diety  firm,  brownish-black  faeces 


DIGESTIVE  AND  ABDOMINAI    ORGANS.         65 

in  small  amount  are  passed.  In  a  diet  of  starchy  foods 
(bread,  potatoes)  the  passage  is  yellow-brown,  soft, 
foamy,  and  in  large  quantity  ;  in  an  exclusively  milk 
diet,  yellow-white  and  firm  ;  in  an  egg  diet,  soft  and  white, 
etc.  Further,  the  color  is  changed  by  drugs,  e.  g.,  iron 
and  bismuth  make  it  black,  forming  sulphate  of  iron 
and  sulphate  of  bismuth  ;  mercurial  preparations,  and 
especially  calomel,  greenish  brown,  making  a  combina- 
tion of  the  coloring  matter  of  the  gall  with  mercury  ; 
rhubarb,  yellow-brown,  and  logwood  preparations,  red- 
dish brown.  Blood  from  the  upper  intestinal  tracts 
mixed  with  the  fseces  makes  a  tarry,  blackish-red  color  ; 
but  if  the  blood  comes  from  the  lower  parts  (in  dysentery 
and  haemorrhoidal  bleeding),  it  is  generally  red  and  un- 
altered. 

In  typhoid  fever  the  stools  generally  have  the  appear- 
ance of  a  badly  cooked  pea-soup  ;  in  cholera  they  re- 
semble rice  water  ;  and  in  dysentery  they  contain  bloody 
mucus. 

In  the  microscopical  exanmiation  of  the  faeces  there  are 
found  shreds  of  cross-striped  muscle  fibres  and  of  the 
animal  tissues  ;  further,  vegetable  substances,  such  as 
spiral  threads,  but  rarely  starch  kernels.  Fat  appears  in 
the  form  of  drops  and  of  glassy  clumps,  as  well  as 
needle-shaped  crystals.  The  latter  point  to  a  disturbed 
fat  absorption,  and  occur  most  abundantly  when  the  gall 
does  not  flow  into  the  intestine.  Also  the  coffin-top- 
shaped  crystals  of  the  ammonia-phosphate  of  magnesia, 
and  clumpy  crystals  of  other  lime  salts,  as  well  as  the 
needle-shaped  crystals  of  Charcot-Neumann,  are  found 
in  the  stools. 

Cellular  elements  are  also  found,  e.  g.,  leucocytes  in  in- 
testinal catarrh,   especially  in   ulcerations.     Red  blood 


66  CLINICAL   DIAGNOSIS, 

corpuscles  are  rarely  seen  in  intestinal  hemorrhage,  as 
they  are  generally  already  destroyed.  Cylindrical  epi- 
thelial cells  are  often  found  in  intestinal  catarrh,  and  are 
often  seen  in  the  process  of  disappearance.  Pavement 
epithelium  in  the  stools  comes  from  the  anus. 

Micro-orga7iis7iis  occur  in  large  numbers  in  the  stools. 
The  proof  of  the  presence  of  the  bacillus  of  tuberculosis 
and  of  Asiatic  cholera  is  of  diagnostic  importance.  The 
presence  of  the  latter  can  be  proved  by  further  culture 
only. 

For  the  account  of  the  animal  parasites  see  Chapter 
XI.,  and  for  the  analysis  of  the  concrements  of  the  gall 
and  faecal  stones  see  Chapter  XIII. 


CHAPTER  IX. 

THE  URINE-PRODUCING  SYSTEM. 
The  Genito-Urinary  Organs. 

The  kidneys  lie  on  both  sides  of  the  vertebral  column 
from  the  level  of  the  twelfth  dorsal  to  the  first  to  third 
lumbar  vertebra.  The  right  kidney  borders  above  on 
the  liver,  the  left  on  the  spleen.  The  lower  and  outer 
borders  of  the  organs  are  determined  by  percussion. 
The  outer  border  is  about  lo  cm.  [4  inches]  external  to 
the  spinous  processes  (renal-hepatic  and  renal-splenic 
angle).  The  kidney  dulness  may  be  absent  in  disloca- 
tion of  the  kidney  (wandering  kidney  is  generally  on  the 
right  side),  or  it  may  be  increased  by  tumors  of  the  kid- 
ney (hydro-nephrosis,  neoplasms  and  echinococcus  of 
the  kidney).  The  latter  may  generally  be  felt  by  press- 
ing deeply  into  the  anterior  abdominal  walls. 

The  urinary  bladder  when  filled  may  generally  be  felt 
and  percussed  as  a  round  tumor  in  the  median  line 
above  the  symphysis  pubis. 

The  Urine. 

The  products  of  decomposition  of  fat  and  of  the  carbohydrates 
leave  the  body  essentially  as  carbonic  acid  and  water  by  the  lungs  ; 
the  last  products,  however,  of  the  decomposition  of  the  albumen 
pass  out  almost  exclusively  in  the  form  of  urine.  Therefore  an  ex- 
amination of  the  urine  gives  us  information,  qualitative  and  quanti- 
tative, as  to  the  passing  out  of  the  products  of  decomposition  of  the 
albumen, 

67 


68  CLINICAL   DIAGNOSIS. 

The  ajHoimt  of  urine  excreted  in  health  by  men  is 
about  1,500  to  2,000  ccm,  [40-60  ounces],  and  by  women 
1,000  to  1,500  ccm.  [30-40  ounces]  in  a  day.  Under  500 
ccm.  [15  ounces]  and  over  3,000  ccm.  [90  ounces]  is 
almost  always  pathological. 

A  lasting  increase  in  the  amount  occurs  in  diabetes  mellitus  and 
insipidus,  in  granular  atrophy  of  the  kidney,  in  pyelitis  as  well  as  in 
absorption  of  collections  of  fluid  in  the  body.  A  decrease  of  urine 
occurs  in  fever,  in  acute  and  chronic  parenchymatous  nephritis,  in 
cholera,  in  profuse  sweating,  as  well  as  in  the  formation  of  exuda- 
tions and  transudations  ;  further  in  valvular  heart  disease,  and  in 
other  diseases  with  lowering  of  the  blood  pressure. 

The  specific  gravity  varies  in  healthy  individuals  under 
ordinary  conditions  of  nourishment,  between  1,015  ^^^ 
1,025.  A  decrease  (1,002)  occurs  in  renal  disease  and  in 
diabetes  insipidus,  an  increase  (1,060)  in  diabetes  mel- 
litus and  in  fever. 

The  specific  gravity  is  measured  by  dipping  the  dry  urinometer 
into  the  fluid  cooled  to  the  surrounding  temperature,  and  then  read- 
ing off  the  amount  at  the  level  of  the  fluid. 

If  the  two  last  figures  of  the  specific  gravity  be  multiplied  by  the 
coefficient  of  Häser  2.33,  the  result  is  approximately  the  amount  (in 
grams)  of  solid  substances  in  1000  ccm.  [30  ounces]  of  urine.  From 
this  the  amount  for  the  24  hours  may  be  calculated.  Thus  if  the 
amount  of  urine  be  2000  ccm.  [60  ounces],  and  the  specific  gravity 
1012,  then  there  are  55.92  grams  [about  530  grains]  of  solid  sub- 
stances in  the  urine. 

2.33  X  12  =  27.96  X  2  =  55.92. 

The  reactio7i  of  normal  human  urine  is  acid,  especially 
on  account  of  the  acid  phosphates  of  sodium  (NaHg 
PO^)  contained  in  it. 

The  acid  reaction  of  the  urine  is  greater  in  proportion 
to  its  concentration — e.  g.,  after  strong  perspiration,  as 
well  as  in  increased  albuminous  metabolism,  as  in  fever. 


THE  URINE-PRODUCING   SYSTEM.  69 

The  reaction  is  slightly  acid,  neutral,  or  alkaline  in  very 
dilute  urine,  and  after  taking  the  alkalies  of  carbonic 
acid  or  vegetable  acid  (the  latter  being  reduced  in  the 
body  to  carbonic  acid,  as  in  a  vegetable  diet)  ;  again, 
when  much  hydrochloric  acid  of  the  stomach  has  been 
removed  from  the  organism  by  habitual  vomiting  or  by 
lavage.  Also  in  the  rapid  absorption  of  exudations  and 
transudations,  the  reaction  of  the  urine  is  less  acid  ; 
whereas  in  the  collection  of  this  fluid,  the  urine  is  strongly 
acid. 

As  soon  as  the  urine  becomes  neutral  or  alkaline,  the 
earthy  phosphates  are  precipitated  (basic  phosphate  of 
lime  and  magnesia  Cag  [PO^]^  and  Mgg  [PO^Jg)  ;  also 
occasionally  the  carbonates  of  the  alkaline  earths  fall  to 
the  bottom  as  a  white  flocculent  sediment.  This  is  dis- 
solved at  once  by  the  addition  of  acids,  but  not  by  heat- 
ing nor  by  adding  alkalies  (which  distinguishes  it  from 
uric  acid  sediment).  Slightly  acid  or  neutral  urine  be- 
comes sometimes  cloudy  on  heating,  by  separating  the 
earthy  phosphates.  This  cloudiness  disappears  on  add- 
ing acids,  or  on  cooling  off — a  thing  which  disti.nguishes 
it  from  the  cloudiness  of  albumen. 

If  the  urine  be  decomposed  by  the  presence  of  bacteria  in 
the  bladder  (cystitis),  or  after  it  has  been  passed,  the  re- 
action is  also  alkaline  (the  alkaline  urine  fermentation) 
from  the  carbonate  of  ammonia  formed  from  the  urea. 
The  ammoniacally  decomposed  urine  has  a  bad  odor 
and  develops  hydrochlorate  of  ammonia  by  holding  over 
it  a  glass  rod  moistened  with  hydrochloric  acid.  While 
there  is  a  moderate  amount  only  of  the  crystals  of 
ammonio-magnesian  phosphates  (Mg  NH^  ^^ ^  '^^  ^'^^ 
sediment  of  non-decomposed  alkaline  urine,  these  crys- 
tals (coffin-lid  crystals)  appear  in  abundance  in  ammonia- 


JO  CLINICAL   DIAGNOSIS. 

cally  decomposed  urine,  which  may  also  contain  in  addi- 
tion the  thorn-apple-shaped  crystals  of  the  urate  of 
ammonia.  The  blue  mark  on  litmus  paper  from  am- 
moniacal  urine  disappears  on  letting  the  paper  dry  in  the 
air,  while  the  blue  spot  from  urine  whose  alkalinity  is 
due  to  a  fixed  alkali  remains  after  the  litmus  paper  is 
dry.  If  there  is  a  sediment  of  pus  in  the  urine,  it  has  a 
crumbly  appearance  if  the  urine  is  acid  ;  while  in  alkalin,e, 
decomposed  urine,  this  sediment  forms  itself  into  balls 
and  mucous,  thick  thread-like  clumps. 

Normal  Constitutents  of  the  Urine. 

U?-ea  (^),  NHg  CO  NH^,  is  freely  soluble  in  water 
and  alcohol.  The  daily  amount  excreted  by  healthy  in- 
dividuals is  between  20-40  grams  [300-600  grains]  ;  it  is 
increased  in  an  albuminous  diet  and  in  an  increased  loss 
of  the  albumen  of  the  body — e.  g.,  in  diabetes  mellitus 
(to  more  than  100  grams  [1,500  grains]  ),  in  fever  (to  50 
grams  [750  grains]  ),  in  phosphorous  poisoning,  and  in 
dyspnoea.  It  is  decreased  in  inasition  (to  9  grams  [135 
grains]  ),  in  a  diet  poor  in  nitrogen  ;  further,  in  uraemia, 
and  in  acute  yellow  atrophy  of  the  liver. 

The  urea  is  changed  by  bacteria  or  through  the  effect 
of  strong  alkalies  into  the  carbonate  of  ammonia,  by 
taking  up  water,  thus  : 

NHg  CO  NHg  -f  2  H3O  =  NH^  CO3  NH^. 

If  urea  be  heated  dry,  biuret  is  formed,  and  its  watery 
solution  added  to  caustic  potash  and  a  drop  of  a  sul- 
phate of  copper  solution,  gives  a  violet  color  (biuret  re- 
action.) 

To  sAow  the  presence  of  urea  (e.  g.,  in  sputa,  vomitus,  transuda- 
tions, etc.),  the  evaporated  fluid  is  extracted  with  alcohol,  filtered, 
the  filtrate  evaporated,  the  residue  dissolved  in  a  little  water  and 


THE  URINE-PRODUCING    SYSTEM.  J I 

concentrated  nitric   acid  added  to  it.     After  standing  in  the  cold  a 
little  while,  the  hexagonal  crystals  of  nitrate  of  urea  appear. 

Since  the  nitrogen  which  appears  in  the  urine,  and  which  comes 
from  the  changes  of  the   albumen   in  the  Fig.  22. 

organism,  not  only  appears  as  urea,  but 
also  in  other  nitrogenous  compounds,  at 
least  in  relatively  small  amounts,  it  is  better 
to  find  out  the  entire  amount  of  nitrogen 
in  the  urine,  instead  of  the  amount  of  urea, 
in  order  to  draw  conclusions  as  to  the 
changes  of  albumen  in  the  organism.  As 
to  the  exact  methods  of  determining  the 
nitrogen  see  the  text-books.^ 

In  order  to   find  out  approximately  the  Nitrate  of  Urea. 

amount  of  nitrogen  in  the  urine,  the   following  modification  of  the 
trituration  method  of  Liebig  by  Pflüger  is  sufficient  : 

A  row  of  thick  drops  of  soda  paste  (a  mixture  of  soda  and  water) 
is  dropped  on  a  glass  plate  which  has  a  black  background,  then  10 
ccm.  [2-3  drachms]  of  urine  are  measured  out  with  a  pipette  and 
dropped  into  a  beaker  glass,  then  let  i  ccm.  [15  drops]  of  a  nitrate 
of  mercury  solution  ^  drop  from  a  graduated  burette  upon  each  one 
of  the  drops  of  soda  paste.  If  the  point  of  contact  of  the  two  drops 
continue  white,  the  nitrate  of  mercury  should  be  added  until  it  turns 
yellow  and  until  the  yellow  does  not  disappear  on  stirring.  Then 
the  amount  of  the  nitrate  of  mercury  used  is  to  be  multiplied  by  0.04 
in  order  to  obtain  the  percentage  of  nitrogen  in  the  urine.  If,  for 
example,  13  ccm.  [|-  ounce]  of  the  nitrate  of  mercury  solution  be  used 
before  the  yellow  color  appears,  the  result  is  13  X  0.04  =  o.  52  ^  N. 

Uric  Acid,  CgH^N^Og. — The  daily  amount  passed 
is  between  0.2  gram  [3  grains]  and  i.o  gram  [15  grains], 

^  Neubauer  und  Vogel,  Anleitung  zur  qualitativen  und  quantitati- 
ven Analyse  des  Harns  ;  Salkowsky  und  Leube,  die  Lehre  vom 
Harn  ;  Löbisch,  Anleitung  zur  Harnanalyse  ;  Hoppe-Seyler,  Hand- 
buch der  physiologisch-  und  pathologisch-chemischen  Analyse,  and 
many  others. 

^  A  litre  [30-32  ounces]  of  mercurial  nitrate  solution  contains 
71.48  grams  [1,070  grains]  of  mercury.  For  its  preparation,  see  the 
text-books  just  mentioned. 


72 


CLINIC  A  L   DIA  GNO  SIS. 


and  it  generally  decreases  and  increases  with  the  varying 
amount  of  urea.  It  is  considerably  increased  m  leu- 
caemia. During  an  attack  of  gout  it  is  said  to  decrease, 
and  after  the  attack  to  increase. 

Uric  acid  is  normally  present  in  the  urine  as  neutral 
urate  of  sodium,  \vhich  is  freely  soluble  in  water.     In 


%4 


Fig.  23. 


Comb-shaped  and  Whetstone-shaped  Crystals  of  Uric  Acid. 

concentrated  and  strongly  acid  urine,  in  fever  and  after 

severe  sweating,  th.Q  add  tc7'ate  of  sodiu7n  is  present  after 

Fig.  24.  the  urine  has  stood  for   some  time  in  the 

^^%^^        cold.     This  acid  urate  of  sodium  is  easily 

^"^Äv^^-fi^   soluble  in  warm  urine,  and  only  with  diffi- 


^  p  culty  soluble  in  the  cold.  Red-colored, 
Brick-dusrsedimentbrickdust  scdlmeut  is  precipitated  (by 
monia!  ^^"^^  °  "'  uroerythrin),  which  is  re-dissolved  on  heat- 
ing, or  on  adding  caustic  potash.  Urate  of  ainmo7iia  is 
found  as  thorn-apple-shaped  crystals  in  Fig.  25. 

decomposed  urine.  Fj-ee  uric  acid.,  which 
is  almost  insoluble  in  water,  often  ap- 
pears in  strongly  acid  urine,  especially 
after  long  standing.  It  forms  at  the 
bottom  of  the  vessel  a  heavy,  hard,  red, 
crystalline  powder,  which  under  the 
microscope  shows  crystals  of  the  shape  of  whetstones, 
combs,  casks,  and  spear-rheads. 


Thorn-apple  -shaped 
Crystals  of  the  Urate  of 
Ammonia. 


THE  URINE-PRODUCING   SYSTEM.  73 

In  order  to  test  for  uric  acid,  some  of  the  substance  (sediment  or 
concrement  of  the  urine)  is  mixed  upon  the  top  of  a  porcelain  cruci- 
ble with  a  few  drops  of  nitric  acid,  and  slowly  evaporated.  An 
orange-red  spot  is  formed,  which  turns  purple  on  adding  ammonia, 
and  blue  on  the  addition  of  caustic  potash.  This  is  called  the 
murexide  test. 

Oxalic  acid,  (COOH)2. — The  daily  amount  is  as  much  as  0.02  [i-] 
grain],  and  it  appears  in  the  sediment    as    oxalate  of         Fig.  26. 
lime  (insoluble   in  acetic  and  soluble  in  hydrochloric 
acid)  in  very  small,   shining,   octahaedral  crystals  (en- 
velope shape),  or  in  needle  shape. 

Sulp  ho -cyanide  of  potash,  SCNK. — The  daily 
amount  excreted  is  0.05  gram  [f^  grain].  It  gives,  Envelope -shaped 
with  diluted  solution  of  the  chloride  of  iron,  a  red  color,  oxSof  Lime. 
which  does  not  disappear  on  adding  hydrochloric  acid,  and  which  is 
soluble  in  ether. 

Hippuric  acid,  C9H9NO3. — The  daily  amount  excreted  is  o. i-i.o 
gram  [i^-iS  grains].  It  is  formed  in  the  kidneys  by  the  combina- 
tion of  benzoic  acid  and  glycocoll,  and  often  appears  in  needle- 
shaped  or  rhombic  prisms,  which  are  like  the  triple  phosphates,  but 
are  insoluble  in  acetic  acid. 

Xanthine,  C5H4N4O8,  and  Hypoxanthine,  C5H4N4O.  —  The 
latter  is  found  in  the  urine  in  leucaemia. 

Creatinine,  C^H^NgO. — The  daily  amount,  0.5-1.0  gram  [7-15 
grains],  is  increased  in  an  abundant  meat  diet  and  in  increased 
metabolic  muscular  change,  and  decreased  in  inanition  and  con- 
valescence. 

Aromatic  oxi-acids,  as  paroxyphenol  acetic  acid,  give  like  the  phenol 
group  a  red  color  when  treated  with  Millon's  reagent. 

The  Phenols:  Carbolic  acid,  CgHgOH,  Hydroquinone,  CgH^ 
(0H)2,  Cressol  CH3CgH60H. — The  phenols  exist  in  the  urine  in 
the  form  of  the  sulphates,  as  the  so-called  ethereal  sulphates.  An 
increase  of  this  denotes  decomposing  processes  in  the  organism. 
To  detect  the  phenols  in  the  urine,  to  100  ccm.  [3  ounces]  of  urine 
5  ccm.  [li  drachms]  of  concentrated  sulphuric  acid  are  added,  and 
the  whole  distilled  in  a  retort.  Bromine  water  is  then  added  to  the 
distillate,  and  if  carbolic  acid  is  present,  there  is  formed  a  yellow- 
white  precipitate  of  tri-bromo-phenol. 

Itidican    (indoxyl    sulphate    of   potassium),   CgHgNO 


74  CLINICAL   DIAGNOSIS. 

SO3K. — Indol,  the  result  of  the  decomposition  of  al- 
bumen in  the  intestinal  canal,  or  of  putrid  suppuration, 
is  re-absorbed  and  oxydized  in  the  organism  to  indoxyl, 
which,  in  the  urine,  combines  with  sulphuric  acid  and 
passes  out  as  the  indoxylsulphate  of  potassium  (indican). 
This  latter  splits  up  on  adding  concentrated  hydrochloric 
acid  and  the  chloride  of  lime  (as  an  oxydizer),  and  forms 
indigo  blue.  Indican  is  increased  by  an  abundant  meat 
diet  ;  further,  in  putrid  suppuration,  in  diseases  of  the 
stomach  and  intestines,  in  abnormal  putrefaction  of  the 
ingesta,  and. is  most  increased  in  intestinal  obstruction. 
From  the  amount  of  indican  in  the  urine  a  conclusion 
may  be  drawn  as  to  the  intensity  of  the  processes  of  the 
decomposition  of  albumen  in  the  intestinal  canal. 

In  order  to  test  for  indican,  to  a  small  quantity  of  urine,  \  of  its 
volume  of  a  10  ,^  solution  of  the  acetate  of  lead  is  added,  by  which  a 
number  of  disturbing  substances  are  j^recipitated,  and  removed  by 
filtration.  To  the  filtrate  is  then  added  an  equal  part  of  hydrochloric 
acid  and  one  or  two  drops  of  a  concentrated  solution  of  calcium 
chloride,  which  is  one  half  diluted  with  water.  The  chloride-of- 
calcium  solution  is  added  drop  by  drop  until  a  blue  color  appears. 
Too  much  chloride  of  calcium  hinders  the  formation  of  the  indigo. 
A  few  ccm.  of  chloroform  are  then  added,  and  the  whole  shaken, 
which  brings  out  the  indigo. 

Inorganic  Constituents  of  the  Urine. 

Hydrochloric  acid  HCl  is  present  principally  combined 
with  sodium  as  common  salt.  The  amount  of  sodium 
chloride  in  the  urine  is  about  one  half  the  amount  of  urea 
present,  /.  <?.,  between  ii  and  15  grams  [150  and  225 
grains].  It  depends  principally  upon  the  amount  of  salt 
taken  with  the  food.  It  is  lessened  in  inanition  and  in 
fever,  especially  in  pneumonia.  Indeed,  in  the  latter  dis- 
ease there  is  often  so  little  present  in  the  urine  that  the 


THE    URINE-PRODUCING   SYSTEM.  75 

addition  of  a  nitrate  of  silver  solution  causes  a  slight 
cloudiness  only,  while  normally  the  chloride  of  silver 
is  precipitated  in  large  quantities.  The  chlorides  are 
increased  (to  as  much  as  55  grams  [825  grains])  dur- 
ing a  rapid  re-absorption  of  exudations. 

Sulphuric  acidYi^'^iO ^.  The  daily  amount  excreted  is 
from  2.0  to  2.5  grams  [|— f  drachm],  and  it  appears  partly 
as  ethereal  sulphuric  acid  in  combination  with  phenol, 
indoxyl,  etc.,  and  partly  as  "  preformed  "  sulphuric  acid. 
The  proportion  of  the  former  to  the  latter  kind  of  sulphu- 
ric acid  is  about  as  1:10.  In  carbolic  acid  poisoning,  how- 
ever, the  entire  amount  of  sulphuric  acid  present  may  be  in 
combination  with  carbolic  acid.  In  order  to  test  for  the 
ethereal  sulphuric  acids  the  urine  is  first  rendered  slightly 
acid  with  acetic  acid  and  then  barium  chloride  is  added 
in  excess,  by  which  the  preformed  sulphuric  acid  alone  is 
precipitated  and  may  then  be  removed  by  filtration. 
The  filtrate  is  then  treated  with  concentrated  hydrochlo- 
ric acid  and  then  heated.  By  decomposition  of  the  ethe- 
real sulphuric  acids  a  precipitate  of  barium  sulphate  is 
formed  from  which  the  amount  of  ethereal  sulphuric  acid 
may  be  determined. 

Phosphoric  acid  HgPO^.  The  daily  amount  excreted 
is  2.5-3.5  grams  [|-i  drachm]  of  which  two  thirds  are 
combined  with  alkalies  and  one  third  with  alkaline 
earths  (lime  and  magnesia).  The  daily  amount  of  the 
earthy  phosphates  is  1.2  grams  [18  grains]. 

Carbonic  acid  COg  is  present  in  human  urine  in  very 
small  quantities  and  is  more  abundant  after  taking  fruit 
and  vegetable  food,  after  many  drugs,  as  well  as  in 
decomposed  urine.  When  large  quantities  of  the  car- 
bonates are  present  the  urine  effervesces  on  the  addition 
of  acids,  and  causes  a  white  deposit  on  a  glass  rod  mois- 


!(> 


CLINICAL  DIAGNOSIS. 


tened  with  baryta  water  and  held  over  the  mouth  of  the 
test  tube.  Carbonate  of  lime  is  present  in  the  sediment 
as  small  spherical  and  biscuit-shaped  [dumb-bell  crystals] 

Fig.  27.  Fig.  28.  Fig-  29- 


Neutral  Phosphates  of 
Lime. 


Coffin-lid  Crystals  of  the  Am- 
monio-Phosphate  of  Magnesia. 


^'1^' 


Spherical  and  Biscuit- 
shaped  [dumb-bell] 
Crystals  of  the  Carbon- 
ate ot  Lime. 

bodies  which  dissolve  with  the  formation  of  bubbles  on 
the  addition  of  acids. 

Sodiitm.  The  daily  amount  excreted  is  4-6  grams 
[i-i|-  drachms],  in  form  of  sodium  oxide  NagO.  Potas- 
simn.  The  daily  amount  excreted  is  2-3  grams  [30-45 
grains],  in  form  of  potassium  oxide  K^O.  During  fever 
the  amount  of  sodium  decreases,  while  the  amount  of 
potassium  is  3  to  7  times  as  great.  Ammonia  NH3  is 
present  in  unfermented  urine  in  small  quantities  only, 
(0.6-0.8  gram  [10-12  grains]).  It  is  much  decreased  in 
many  cases  of  diabetes.  Calciu7n.  The  daily  amount 
excreted  is  0.16  gram  \2\  grains],  in  form  of  CaO. 
Mag7iesiu7n.  The  daily  amount  excreted  is  0.23  gram 
[3}  g^^i^s],  in  form  of  MgO. 

The  sulphate  of  calcium  (gypsum)  is  present  in  the 
sediment  in  form  of  fine  oblique  prisms  and  needles, 
which  are  not  soluble  in  acetic  acid.  Neutral  phosphate 
of  calcium  is  present  in  form  of  wedge-shaped  crystals 
which  unite  to  form  rosettes.  The  ammonio-magnesian 
phosphates^  or  triple  phosphates,  occur  as  shining  coffin- 
lid-shaped  crystals.  The  two  last  of  these  crystals  men- 
tioned are  soluble  in  acetic  acid. 


THE    URINE-PRODUCING   SYSTEM.  "JJ 

Iron  is  present  in  the  organism  in  combination  and 
therefore  appears  in  the  ash  of  urine  only. 

Pathological  Constituents  of  the  Urine. 

Albumen  (serum  albumen  and  serum  globulin).  In  order 
to  make  use  of  the  following  tests,  the  urine  should  be 
clear,  and  filtered  if  not  clear. 

I.  Heat  Test. — The  urine  is  heated  to  the  boiling  point  in  a  test- 
tube,  and  then  one  or  two  drops  of  diluted  acetic  acid  should  be 
added.  Instead  of  the  acetic  acid,  nitric  acid  may  be  used,  in 
which  case  ten  to  twenty  drops  should  be  added.  If  the  cloudiness 
caused  by  heating  be  dissolved  by  the  acid,  then  it  was  not  caused  by 
albumen,  but  by  the  phosphates  and  carbonates  of  lime  and  magnesia 
which  are  freely  soluble  in  the  acids.  If  the  cloudiness  remain,  or  if 
it  appear  on  the  addition  of  acid,  it  is  caused  by  albumen. 

A  cloudiness  often  appears  after  adding  acetic  acid  to  the  urine 
when  it  is  warm,  or  when  it  has  cooled  off.  In  this  case  it  is  not  due 
to  mucin,  but  to  albumen. 

If  the  precipitate  of  albumen  be  taken  from  the  filter  and  its  vol- 
ume approximated  after  three  to  twelve  hours,  an  approximate 
result,  as  to  the  amount  per  cent,  of  albumen  in  the  urine  may  be 
obtained.  When  the  amount  of  albumen  is  2  ^  to  3  ^,  the  whole 
fluid  is  completely  coagulated.  When  there  is  i  ^  of  albumen  pres- 
ent, the  coagulum  in  the  test-tube  reaches  half  way  up  to  the  level 
of  the  urine. 

When  o.  5     ^,  \  the  way  up. 


1   <' 


"    0.1    ^,  Jo 

"  0.05  %,  the  curved  part  of  the  tube  is  barely  filled  with  albu- 
men, and  when  there  is  less  than  o.oi  %  present,  there  is  a  slight 
cloudiness,  but  no  precipitate. 

II.  Heller  s  Test. — The  test-tube  containing  the  urine  is  held  ob- 
liquely and  concentrated  nitric  acid  is  poured  slowly  down  the  side 
of  the  tube  so  as  to  flow  below  the  urine.  If  albumen  be  present, 
there  is  formed  a  sharply  defined  ring-shaped  cloudiness  at  the  point 
of  contact  between  the  urine  and  the  acid.  Besides  albumen,  a  pre- 
cipitate in  very  concentrated  urine  may  be  caused  by  the  presence  of 


78  CLINICAL   DIAGNOSIS. 

urea,  in  which  case  the  ring  is  higher  and  not  so  clear.  A  cloudi- 
ness may  also  be  caused  by  nitrate  of  urea,  and  in  this  case  the  pre- 
cipitate is  crystalline  and  does  not  appear  until  after  standing  a  long 
time.  A  cloudiness  may  occur  from  the  resinous  substances,  as  after 
taking  copaiva,  styrax,  turpentine,  etc.,  but  in  this  case  the  precipi- 
tate is  dissolved,  after  cooling,  in  alcohol.  The  ring  of  albumen 
may  be  colored  blue  or  green  by  indigo,  or  by  the  coloring  matter  of 
the  gall. 

III.  Test  with  Acetic  Acid  and  Ferrocyanide  of  Potassium  in  the 
cold. — If  to  some  urine  three  to  five  drops  each  of  acetic  acid  and 
a  lo  ^  solution  of  ferrocyanide  of  potassium  be  added,  there  occurs 
a  precipitate  from  the  presence  of  albumen  or  hemialbtcmose.  If 
the  urine  be  taken  in  very  small  quantities,  the  precipitate  appears 
only  after  a  few  minutes. 

IV.  Biuret  Test. — The  urine  is  first  to  be  made  alkaline  with 
caustic  potash,  and  then  1-3  drops  of  a  diluted  solution  of  sulphate 
of  copper  are  to  be  added,  and  if  albumen,  hemialhtanose,  or  peptone 
be  present,  a  reddish  violet  solution  is  formed. 

[V.  Picric  Acid  Test. — A  delicate  and  convenient  test  used  long 
ago  in  Germany  and  rediscovered  in  1882  by  George  Johnson.  The 
dry  acid  may  be  dissolved  in  the  urine,  or  a  saturated  solution  may 
be  used,  into  which  the  urine  should  be  slowly  dropped,  and  if  albu- 
men is  present  a  cloudiness  appears  at  once.] 

For  the  quantitative  determination  of  albumen,  see  Chapter  X. 

Heinialbuinose  (Propeptone)  is  an  intermediate  state  be 
tween  albumen  and  peptone.  This  is  not  precipitated 
by  heating,  but  by  nitric  acid,  acetic  acid,  and  ferro- 
cyanide of  potassium,  as  well  as  by  acetic  acid  and  so- 
dium chloride.  All  these  precipitates  have  the  property 
of  dissolving  on  heating  and  reprecipitating  on  cooling. 

To  test  for  hemialbumose  it  is  necessary,  first,  to  remove  the  albu- 
men. For  this  purpose,  to  the  urine  (or  to  any  other  fluid  to  be  ex- 
amined, as  the  contents  of  the  stomach)  5  to  10  drops  of  acetic  acid 
and  \  of  its  volume  of  a  concentrated  salt  solution  are  added,  and  the 
whole  heated.  Then  the  albumen  will  be  precipitated  and  should 
be  removed  while  hot  by  filtration,  while  the  filtrate  is  allowed  to 
cool  off.      If  a  cloudiness  now  arise  on  the  addition   of  salt   solution 


THE    URINE.PRODUCING   SYSTEM.  79 

to  the  filtrate  then  hemialbumose  is  present.  If  too  much  salt  solu- 
tion be  added,  the  precipitate  of  hemialbumose  cannot  be  redissolved 
by  heat. 

Peptojies  are  present  in  the  urine  principally  in  the  ab- 
sorption of  pus  and  exudations  (pneumonia,  empyema, 
abscesses  and  puerperal  fever,  etc.)  They  are  not  pre- 
cipitated on  heating,  nor  with  nitric  nor  acetic  acid,  nor 
with  ferro-cyanide  of  potassium.  They  a:^e  tested  for 
with  the  biuret  test  after  the  albumen  and  hemialbumose 
have  been  removed  or  proved  absent. 

10  ccm.  \2.\  drachms]  of  a  concentrated  solution  of  sodium  acetate 
and  a  few  drops  of  a  solution  of  iron  chloride  are  added  to  500  ccm. 
[i  pint]  of  urine  until  there  results  a  permanent  red  color  ;  then  a 
caustic  potash  solution  is  dropped  carefully  into  this  mixture  until 
it  is  slightly  acid  or  neutral,  and  the  mixture  heated.  After  it  has 
cooled  off  and  been  filtered,  the  filtrate,  which  ought  to  be  entirely 
free  from  albumen,  is  subjected  to  the  biuret  test. 

Blood. — We  speak  of  hasmaturia  when  the  blood  color- 
ing matter  is  present  in  the  urine  in  combination  with 
the  blood  corpuscles  ;  of  hsemoglobinuria  when  the  blood 
coloring  matter  is  in  solution  without  there  being  blood 
corpuscles  in  the  sediment.  The  latter  occurs  when 
the  blood  corpuscles  are  dissolved  by  some  agent  (after 
poisoning,  cold,  etc.),  and  the  haemoglobin  becomes  free. 

Urine  containing  blood-coloring  matter  is  either  bright  red  with  a 
greenish  iridescence  (resembling  meat  juice)  from  the  presence  of  oxy- 
haemoglobin,  or  it  is  a  dark  brownish-red  from  the  presence  of  meta- 
hsemoglobin.  The  latter  differs  from  oxyhasmoglobin  by  its  being 
recognized  in  the  spectroscope  as  a  dark  absorption  line  in  the  red 
and  a  paler  one  between  the  green  and  blue  near  both  the  oxyhsemo- 
globin  lines.  ^ 

^  The  spectroscopic  examination  may  be  made  with  the  pocket 
spectroscope.  The  urine  is  held  in  a  tube  before  the  slit  m  the  in- 
strument. 


80  CLINICAL   DIAGNOSIS. 

Besides,  the  spectroscopic  test  blood-coloring  matter  may  also  be 
recognized  by  the  following  tests  : 

Heller  s  Test. — If  the  urine  be  heated  with  caustic  potash,  the 
earthy  phosphates  in  precipating  take  the  coloring  matter  of  the 
blood  with  them,  and  appear  reddish  brown  instead  of  white. 

Giiaiac  Test. — About  i  ccm  [15  drops]  of  a  freshly  made  tincture 
of  guaiac  and  the  same  amount  of  resinous  turpentine  oil  are  added 
to  some  urine  and  well  shaken.  If  blood  be  present  the  mixture 
turns  blue  after  a  few  minutes.  Instead  of  turpentine  oil,  Hiihner- 
feld's  mixture  ^  may  be  used. 

The  smallest  amount  of  blood  which  can  no  longer  be  recognized 
by  one  of  these  methods  may  be  looked  for  by  examining  the  sedi- 
ment microscopically  for  blood  corpuscles. 

Coloring  matter  of  the  bile.  In  urine  there  is  present 
either  the  actual  coloring  matter  of  the  bile  (bilirubin) 
which  is  changed  by  Oxydation  into  green  (biliverdin), 
violet,  red,  and  yellow  (choletelin),  or  hydro-bilirtibin 
(urobilin),  which  originates  from  a  reduction  of  the  col- 
oring matter  of  the  gall  and  blood.  Urine  containing 
bilirubin  is  of  a  beer-brown  color  and  has  a  yellow  foam 
on  shaking.  On  being  shaken  with  chloroform  the  bili- 
rubin becomes  gold-yellow  and  is  taken  up  by  the  chlo- 
roform. 

Bilirubin  is  tested  for  by  the  Gmelin  test.  A  few  drops  of  fu- 
ming nitric  acid  are  added  to  concentrated  nitric  acid  until  a  slight 
yellow  is  observed.  This  mixture  is  then  poured  into  a  vessel  con- 
taining urine  in  such  a  way  that  the  acid  passes  down  the  side  of  the 
glass  under  the  urine.  Then  there  is  formed  at  the  point  of  contact 
of  the  acid  and  the  urine,  a  colored  ring  which  passes  from  green 
through  violet  to  red  and  yellow.     A  blue  ring  alone  may  be  caused 

^  Glacial  acetic  acid,  2.0  ccm  [30  drops]. 
Distilled  water,  i.o  ccm  [15  drops]. 
Oil  of  turpentine, 
Absolute  alcohol. 
Chloroform, — of  each  roo.o  ccm  [3  ounces]. 


THE    URINE-PRODUCING  SYSTEM.  8 1 

by  indigo,  a  reddish-brown  one  by  hydrobilirubin  and  other  substan- 
ces. 

If  a  solution  of  iodine  in  iodide  of  potash  be  added  to  the  urine 
containing  biHrubin,  it  becomes  a  green  (biliverdin). 

Hydrobilirubin  is  tested  for  by  adding  to  urine  2-5  drops  of  a 
10  %  solution  of  the  chloride  of  zinc,  and  afterwards  enough  ammonia 
to  redissolve  the  precipitated  oxide  of  zinc.  If  a  green  fluores- 
cence is  observ^ed  (by  looking  at  the  test-tube  against  a  dark  back- 
ground) in  the  fluid  filtered  from  the  precipitated  phosphates,  hydro- 
bilirubin is  present.  Instead  of  the  chloride  of  zinc  and  ammonia, 
iodine-iodide  of  potash  and  caustic  potash  may  be  used.  In  the 
spectroscopic  examination  of  urine  containing  hydrobilirubin  (even 
after  adding  the  chloride  of  zinc  and  ammonia),  it  may  be  recognized 
by  an  absorption  line  between  the  green  and  the  blue. 

Gallic  acids  are  found  by  Fettenkoffer  s  test  :  A  grain  of  cane 
sugar  is  added  to  the  fluid  and  the  whole  is  evaporated  with  gentle 
heat  on  the  cover  of  a  porcelain  crucible  with  a  drop  of  concentrated 
sulphuric  acid.  If  the  gallic  scids  are  present  the  fluid  becomes 
purple.  The  same  reaction  may  be  caused  by  other  substances 
(albumen,  fatty  acids,  etc.),  so  that  the  gallic  acids  should  first  be 
extracted  from  the  urine.  For  the  procedure  necessary  (as  evapo- 
rating, extracting  with  alcohol,  precipitating  with  bar}'ta  and  ex- 
tracting the  cholalate  of  barj^ta  with  warm  water),  see  the  text-books. 

Grape  Sugar  (Dextrose)  CgH^gOg  is  fermented  by 
yeast  to  alcohol  and  carbonic  acid  (—  2C2HgOH  -j- 
2CO2),  shows  a  brown  color  when  heated  with  caustic 
potash,  is  capable  of  reducing,  and  turns  the  plane  of 
polarized  light  to  the  right. 

I.  To  make  the  fermentation  test,  a  test-tube  or  eudiometer  tube 
is  first  half  filled  with  mercury,  and  the  same  amount  of  urine  is 
added,  only  leaving  enough  room  for  a  little  yeast.  The  air  bubbles 
are  removed  from  the  opening  of  the  tube,  which  is  then  closed  by 
the  finger,  and  dipped  upside  down  under  mercury,  and  left  there  at 
a  temperature  not  over  30°  C  [86°  FJ,  The  presence  of  grape  sugar 
soon  causes  a  development  of  gas.  In  order  to  show  that  the  gas  is 
carbonic  acid,  some  caustic  potash  is  introduced  through  a  curved 
pipette  into  the  tube,   and  by  this  the  carbonic  acid  is  absorbed. 


82  CLIiVICAL   DIAGNOSIS. 

This  determines  the  presence  of  grape  sugar.  Much  more  conven- 
ient are  the  ?,o-ca.\\Q^  fe7'vie}ttatio7i  tubes}  A  piece  of  yeast  as  large 
as  a  pea  is  introduced  into  one  of  the  tubes  and  urine  is  so  added 
that  no  air  enters  into  the  vertical  branch  of  the  tube.  For  the 
sake  of  greater  certainty  a  second  tube  with  a  dextrose  solution  and 
yeast,  and  a  third  tube  with  normal  urine  and  yeast,  may  be  also 
used.  If  the  result  of  the  second  test  is  positive,  this  shows  that 
the  yeast  is  effective,  and  if  the  result  of  the  third  test  is  negative, 
it  shows  that  the  urine  contains  no  sugar. 

By  determining  the  specific  gravity  of  urine  both  before  and 
after  fermentation  (after  24  hours  at  the  temperature  of  the 
room),  the  approximate  amount  of  grape  sugar  may  be  obtained. 
The  urine  is  made  to  ferment  with  yeast  in  a  long-neck  bottle,  the 
opening  being  covered  with  a  watch  glass  to  prevent  evaporation. 
After  24  hours  the  specific  gravity  of  the  filtered  urine  is  taken  at 
the  same  temperature.  The  difference  in  the  specific  gravity  before 
and  after  the  fermentation  is  read  from  the  urinometer,  each  degree 
of  which  corresponds  to  0.219  ^  of  sugar.  Thus  urine  which  before 
the  fermentation  had  a  specific  gravity  of  1040,  and  after,  the  specific 
gravity  of  1020,  contains  4.38  %  of  sugar. 

II.  Moore  s  Test.  If  urine  containing  sugar  be  heated  a  few 
minutes  with  one  third  its  volume  of  a  concentrated  caustic  potash 
solution,  it  turns  brown.  This  test  is  reliable  only  when  the  brown 
color  is  very  intense,  for  sugar  to  the  amount  of  0.5  %  cannot  thus  be 
found.  With  i  %  of  sugar  the  color  becomes  canary  yellow,  2  %  am- 
ber yellow,  5  ^  the  color  of  Jamaica  rum,  and  7  ^  it  becomes  blackish 
brown  and  non-transparent. 

III.  Reduction  Tests. 

{a)  Trommers  Test. — To  a  quantity  of  urine,  one  third  its  volume 
of  a  caustic  potash  or  soda  solution  is  added,  and  then  1-2  drops  of  a 
diluted  (5-10  ^)  sulphate  of  copper  solution.  If  the  bright  blue- 
colored  precipitate  of  hydrated  copper  oxide  remains  undissolved 
and  flocculent  on  shaking,  no  sugar  is  present.  In  the  presence  of 
sugar,  glycerine,  tartaric  acid,  ammonia,  or  albumen  the  hydrated 
cupric  oxide  dissolves,  giving  the  urine  a  sky-blue  color.  The 
sulphate  of  copper  solution  should  be  added  drop  by  drop  until  there 

^  To  be  had  of  Hildenbrand  in  Erlangen,  and  Dr.  R.  Muenke  in 
Berlin,  N,  W.,  Luisenstrasse,  58. 


THE    URINE-PRODUCING   SYSTEM.  83 

is  only  a  small  part  left  undissolved  on  shaking  the  tube.  If  this 
mixture  be  then  heated  the  presence  of  sugar  will  cause,  before  the 
boiling  point  is  reached,  a  yellow-red  precipitate  of  cuprous  oxide 
(CU3O),  formed  by  the  grape  sugar  taking  oxygen  from  the  cupric 
oxide  (CuO).  If  the  fluid  change  color  v/ithout  forming  a  precipitate, 
or  if  the  latter  be  not  formed  until  the  urine  has  cooled  off,  then  the  test 
is  not  convincing,  since  other  reducing  substances  (uric  acid,  Creatinin, 
etc.)  hold  the  cuprous  oxide  in  solution.  Exceptionally  reducing 
substances  appear  in  the  urine  from  medicines  taken  (turpentine, 
chloral  hydrate,  chloroform,  benzoic  acid,  salicylic  acid,  camphor, 
copaiva,  and  cubebs).  It  is  generally  a  more  certain  test  to  let  the 
urine  stand  for  24  hours,  cold,  after  adding  the  substances,  instead  of 
heating  it.  If  then  a  yellow  precipitate  of  cuprous  oxide  appear,  it 
can  be  caused  by  sugar  alone. 

(3)  Test  with  Fe  kling' s  solution. — Fehling's  solution  consists  of 

Crystalline  sulphate  of  copper  34.639  [520  grains]. 
Neutral  tartrate  of  potash  173.0  [5^-  ounces]. 
Ofhcinal  caustic  soda  solution  100. o  [3  ounces]. 
Distilled  water  enough  to  make  1000. o  [30  ounces]. 

One  ccm.  [15  drops]  of  this  is  exactly  reduced  by  0.005  gram 
[y^3  grain]  of  grape  sugar.  Two  ccm.  [30  drops]  of  this  fluid  are  put 
into  a  test  tube,  diluted  with  an  equal  amount  of  water  and  heated. 
In  case  the  formation  of  the  oxides  takes  place,  which  would  make 
it  unfit  for  use,  a  few  ccm  of  urine  which  have  been  previously 
heated  in  another  test-tube  are  added  to  this.  If  grape  sugar  be 
present,  a  yellowish-red  precipitate  is  formed. 

In  order  to  appro xi77iately  determine  quantitatively  the  amount  of 
grape  sugar  present,  the  trituration  method  of  Fehling  may  be  car- 
ried out  on  a  small  scale.  Two  ccm.  [30  drops]  of  Fehling's  solution 
(corresponding  to  0.0 1  gram  [|-  grain]  of  sugar)  are  measured  off  in  a 
large  test-tube  and  diluted  with  about  ten  times  its  volume  of  water  and 
heated.  By  means  of  a  dropper  1-3  drops  of  urine  are  then  added, 
and  the  whole  is  heated,  observing  whether  the  fluid  still  shows  a 
blue  color  on  holding  it  to  the  light.  Is  this  the  case,  then  a  few 
more  drops  are  added,  and  it  is  again  heated  and  again  observed  and 
then  watched  until  the  last  trace  of  blue  has  just  completely  dis- 
appeared, showing  that  all  the  cuprous  oxide  has  been  reduced.  We 
know  that  in  the  urine  there  is  exactly  o.oi  gram  [^  grain]  of  sugar, 


84' 


CLINICAL  DIAGNOSIS. 


and  counting  20  drops  to  i  ccm.  we  can  calculate  the  percentage  of 
sugar  present.  In  order  to  save  the  time  and  trouble  of  making  such 
calculation  at  every  examination,  the  following  table  will  be  found 
convenient.  It  is  better  to  dilute  tne  urine  four  or  five  times  in  a 
graduated  glass. 


Drops  = 

%  Sugar. 

Drops  = 

fc  Sugar. 

Drops  = 

% 

Sugar. 

I 

20 

lO 

2.0 

25 

0.8 

2 

lO 

II 

1.8 

30 

0.6 

3 

6.6 

12 

1.6 

40 

0.5 

4 

5 

13 

1.5 

50 

0.4 

5 

4 

14 

1.4 

60 

0.3 

6 

3-3 

15 

1-3 

70 

0.28 

7 

2.8 

i6 

1.2 

80 

0.25 

8 

2.5 

i8 

I.I 

90 

0.21 

9 

2.2 

20 

I.O 

100 

0.20 

{c)  Böttge7's  Test. — The  urine  is  made  alkaline  by  saturating  it 
with  sodium  carbonate  in  substance,  adding  a  pinch  of  the  subnitrate 
of  bismuth  (NOgBiOHg)  and  heating  it  a  few  minutes.  Or  the  urine 
may  be  heated  with  -J-g-  of  its  volume  of  Nylander's  solution.  This 
solution  consists  of  neutral  tartrate  of  potash  4.0  grams  [l  drachm], 
\o%  solution  of  caustic  soda  100  ccm.  [3  ounces],  to  which  are 
added,  subnitrate  of  bismuth  2.0  grams  [30  grains]  while  warm, 
and  the  whole  to  be  filtered  after  cooling  off.  In  the  presence  of 
grape  sugar  a  broM^n  or  black  color  is  formed,  due  to  the  metallic 
bismuth. 

{d)  Mulde?'  s  Test. — The  urine  is  first  made  alkaline  with  carbon- 
ate of  sodium,  and  then  a  solution  of  indigo  carmine  (sulphate  of 
indigo)  is  added  until  the  urine  turns  blue.  On  heating,  the  indigo 
blue  is  reduced  by  the  grape  sugar  present  to  indigo  white,  and  on 
exposure  to  the  air  again,  turns  blue. 

IV.  Test  with  Phenylhydrazin. — Two  pinches  of  Phenylhydrazin 
and  four  pinches  of  the  acetate  of  sodium  are  put  into  a  test-tube, 
which  is  then  half  filled  with  water  and  heated.  Then  an  equal  vol- 
ume of  urine  is  added,  and  the  test-tube  is  heated  for  20  minutes 
in  a  water  bath  and  allowed  to  cool  off.  When  the  urine  contains  a 
large  amount  of  grape  sugar,  a  yellow  crystalline  precipitate  of 
phenylglucosazone  is  formed,  and  when  there  is  only  a  little  grape 


THE    URINE-PRODUCING   SYSTEM.  85 

suger  present  the  sediment  under  the  microscope  shows  these  crys- 
tals of  this  form  (v.  Jaksch). 

V.  Polariaztion  Test. — The  specific  angle  of  grape  sugar  for  yel- 
low sodium  light  {ex)  D  is  53°.  From  the  degree  of  deviation  a.  in 
the  special  case,  and  the  length  /  of  the  tube  used  expressed  in 
decimeters,  the  percentage  of  grape  sugar  in  the  urine  may  be  calcu- 
lated from  the  formula  f>  =  — 1^ 

53./ 

With  the  presence  of  substances  turning  the  light  to  the  left,  as 

albumen  or  oxybutyric  acid,  the  determination  by  polorization  is  of 
little  value  ;  therefore  it  is  best  to  ferment  the  urine  and  then  polar- 
ize it  a  second  time.  Dark  or  cloudy  urine  should  be  made  clear  by 
the  addition  of  -^^  its  volume  of  sugar-of-lead  solution  in  a  measure 
glass,  and  the  dilution  should  of  course  be  taken  into  account. 

Sugar  0/  milk  (lactose),  Ci^H^^O^,  is  present  in  the  urine 
of  nursing  lying-in  women.  It  has  a  right  rotatory- 
power  (/-^)d  =  52.5,  and  passes  over  with  difficulty  into 
alcoholic  fermentation  and  rarely  into  lactic  acid  fer- 
mentation.     It  has  the  property  of  reduction. 

Inosite^  CgHj^Og,  is  present  in  polyuria.  It  is  neither 
fermentable,  nor  does  it  possess  the  power  of  polariza- 
tion nor  of  reduction.  For  its  formation  see  the  text- 
books. 

Acetone^  CH3COCH3,  is  present  in  urine  in  febrile 
diseases,  in  diabetes,  in  certain  forms  of  carcinoma,  and 
in  inanition  and  auto-intoxication. 

To  test  for  the  acetones  a  few  drops  of  freshly-prepared  nitro- 
ferrocyanide  of  sodium  are  added  to  the  urine,  and  then  a  strong 
caustic  soda  solution,  until  it  is  decidedly  alkaline.  When  the 
beginning  purple  tint  turns  yellow,  I  to  3  drops  of  concentrated 
acetic  acid  are  added,  and  if  the  acetones  be  present  a  crimson- 
purple  color  is  formed  at  the  point  of  contact  of  the  acetic  acid  and 
the  mixture  (Legal's  test).  It  is  better  to  distill  the  urine  with 
some  muriatic  acid,  and  to  test  the  distillate  for  acetone  with 
Lieben's  test.  According  to  the  latter  a  few  drops  of  a  solution  of 
iodine  in  iodide  of  potash  and  caustic  potash  are  added  to  a  few 


S6  CLINICAL   DIAGNOSIS. 

ccm.    of  the  distillate.      If    the  acetone  be   present,  a  yellow-white 
precipitate  of  iodoform  appears  at  once. 

Diacetic  add,  CHgCOCH^COOH,  is  present  in  the  urine 
in  many  grave  cases  of  the  contagious  diseases,  in  grave 
cases  of  diabetes,  carcinoma,  and  in  auto-intoxication. 

If  to  some  urine  one  or  two  drops  of  a  solution  of  the  chloride  of 
iron  be  added,  a  gray  or  chocolate-colored  precipitate  of  the  phos- 
phate of  iron  appears.  If  more  iron  chloride  be  added,  the  presence 
of  diacetic  acid  gives  the  urine  a  da7'k  Bordeaux-red  color  (the  iron 
chloride  reaction  of  Gerhardt),  which  disappears  at  once  on  adding 
sulphuric  acid.  If  the  urine  be  heated  first,  then  the  reaction  is 
very  slight  or  not  at  all.  If  the  urine  already  made  acid  with  sul- 
phuric acid  be  extracted  with  ether,  the  ether  takes  up  the  diacetic 
acid,  and  may  be  tested  for  with  iron  chloride.  Still  even  this  re- 
action disappears  in  24-48  hours.  A  brown-red  color  of  the  urine 
with  iron  chloride  does  not  determine  the  presence  of  diacetic  acid. 
If  the  urine  be  distilled  the  diacetic  acid  splits  up  into  acetone  and 
carbonic  acid,  and  the  acetone  may  then  be  determined  by  Lieben's 
test. 

Diazoreaction  (Ehrlich).  Sulphodiazobenzole  unites 
with  different  kinds  of  unknown  aromatic  substances  of 
the  urine  to  form  colored  compounds. 

To  prepare  this  reagent  two  solutions  are  necessary  : 

a)  Sulphanile  acid 5.0  [75  drops]. 

Muriatic  acid     . 50.0  [i I- ounces]. 

Distilled  water looo.o  [30  ounces]. 

And 

V)  Nitrite  of  sodium Oo  [8  grains]. 

Water 100.0  [3  ounces]. 

When  ready  for  use  5  ccm.  [75  drops]  of  solution  b)  are  to  be  added 
to  250  ccm.  [8  ounces]  of  solution  a),  and  this  "  reagent  "  should  be 
prepared  fresh  for  every  test.  Then  to  equal  parts  of  this  reagent 
and  urine  \  volume  of  ammonia  is  added,  and  shaken  up.  In  cer- 
tam  (febrile)  diseases  the  fluid  turns  red  (scarlet,  orange,  orange- 


THE   UklNE-PliODUCWG  SYSTEM. 


87 


red),  which  is  especially  noticeable  in  the  foam  (red  reaction).  This 
color  is  noticeable  in  typhoid  fever  (from  the  first  week  on),  some- 
times in  relapses,  also  in  grave  cases  of  phthisis  pulmonum,  pneu- 
monia, measles.  The  disappearance  of  this  reaction  is  considered  a 
good  sign. 

Melanine. — In  the  urine  of  those  suffering  from  melanotic  carci- 
noma, melanogen  is  sometimes  present,  which  forms  black  clouds  of 
melanine  on  adding  concentrated  nitric  acid  or  chromic  acid  to  the 
urine.  At  times  the  urine  is  dark  from  the  presence  of  formed  mel- 
anine in  the  urine. 

Stilphtc?'etted  hydrogen,  HgS,  is  present  principally  in  decomposed 
urine,  as  in  cystitis.  Since  it  is  found  in  normal  urine  after  long 
standing,  only  fresh  urine  should  be  taken.  A  few  drops  of  muriatic 
acid  are  added  to  the  urine  in  a  bottle,  and  the  opening  is  covered 
with  filter-paper  which  has  been  moistened  with  a  sugar-of-lead 
solution.  If  HgS  be  present  the  moistened  paper  turns  dark  from 
the  formation  of  the  sulphide  of  lead. 

Leucine  ox  Amidocaproic  acid,  and  Tyrosine  ox  Amido-Hydroparacu- 
vtaric  acid  are  present  in  the  urine  principally  in  acute  yellow  atrophy 
of  the  liver  and  in 
phosphorus  poisoning. 
Leucine  appears  in 
yellow  globules,  which 
have  a  fatty  gloss  and 
are  often  marked  with 
radiating  lines.  Ty- 
rosine is  in  the  form 
of  fine  bundles  of 
needles  or  globules.  The  urine  is  evaporated  to  syrupy  consistency 
and  left  in  the  cold  to  crystallize,  and  then  examined  microscopically. 

Cystine  is  occasionally  present  in  the  sediment  in  the  form  of  color- 
less shining  hexagonal  plates. 

Fat  is  occasionally  present  as  a  fine  cloudiness  and  gives  the 
urine  a  milky  appearance  (chyluria).  This  milkiness  disappears  on 
adding  caustic  potash  and  shaking  up  with  ether. 

Test  for  Drugs. 

Iodine  and  Bromine. — Freshly  made  chlorine  water  or  strong 
fuming  nitric  acid  is  added  to  the  urine  and  then  shaken  with  a  iQ.w 


Fig.  30. 


Fig.  31. 


Leucine. 


Tyrosine. 


SS  CLINICAL   DIAGXOSIS. 

ccm.  of  chloroform,  which  is  then  colored  carmine  red  if  iodine 
is  present,  and  brownish  yellow  if  bromine  is  present. 

Nitric  acid. — A  brucine  solution  is  added  to  the  urine  and  the  sul- 
phuric acid  is  allowed  to  trickle  down  the  side  of  the  glass  and  at  the 
point  of  contact  a  red  ring  is  formed.  The  same  reaction  may  be 
caused  by  other  bodies  (as  hydrobüirubin). 

Lithium. — The  flame  reaction  or  a  spectroscopic  examination  of 
the  ash  is  sufficient. 

Arsenic. — After  remo-\-ing  the  organic  substances  -näth  muriatic 
acid  and  chlorate  of  potash,  the  fluid  is  examined  according  to 
Marsh's  test. 

Lead. — Fresh  muriatic  acid  and  chlorate  of  potash  are  added 
to  destroy  the  organized  substances,  the  chlorine  is  driven  off,  then 
the  mixture  is  filtered  off  and  sulphuretted  hydrogen  conducted 
through  it,  and  if  lead  be  present  a  brown  color,  due  to  the  sulphide 
of  lead,  is  formed. 

Mercury. — To  the  urine  of  one  day,  lo  ccm.  [2  drachms]  of 
muriatic  acid  and  a  small  quantity  of  brass  or  copper  shavings  are 
added,  and  the  whole  is  heated.  After  24  hours  the  urine  is  poured 
off  and  the  metal  washed  several  times  in  water  made  slightly  alka- 
line with  caustic  potash,  then  washed  with  alcohol,  then  with  ether, 
and  then  let  dry.  The  metal  is  then  brought  into  a  long  large  dccy 
test-tube  and  heated  red-hot.  If  the  mercury-  be  present  it  has 
already  amalgamated  itself  with  the  copper  or  brass  and  the  heat 
volatilized  it  and  caused  it  to  be  condensed  on  the  cool  parts  of  the 
tube.  Now,  if  fumes  of  iodine  be  introduced  into  the  tube  the  mer- 
cury is  changed  to  the  iodide  of  mercury  which  appears  as  a 
red  tinge,  and  by  careful  heating  may  be  condensed  to  a  sharply  de- 
fined ring. 

Quiniiu. — 500  cm.  [15  ounces]  are  made  alkaline  with  caustic 
potash  and  shaken  five  minutes  Avith  ether.  The  ether  is  then 
brought  to  the  surface  and  evaporated  off,  and  the  remainder  taken 
up  with  water  and  a  few  drops  of  muriatic  acid.  This  fluid  shows  a 
blue  fluorescence  on  adding  a  drop  of  sulphuric  acid,  or,  if  treated 
with  strong  chlorine  water  and  concentrated  ammonia,  it  shows  a 
green  ring. 

Carbolic  acid  (Phenol  CgHjOHj  —  When  much  carbolic  acid  has 
been  ingested  the  urine  becomes  greenish  brown  and  turns  dark 
when  exposed  to  the  air,  just  as  t!ie  urine  does  after  taking  hydro- 


THE    URINE-PRODUCING   SYSTEM.  89 

quinone  (C6H4(OH)2),  folia  uvse  ursi,  and  tar.  For  the  beha\äor 
of  sulphuric  acid  in  carbolic  acid  intoxication,  a,nd  the  detection 
of  carbolic  acid,  see  pages  73  and  75. 

Salicylic  acid  (Oxybenzoic  acid).  — The  urine  turns  violet  on  adding 
chloride  of  iron. 

Antipyrin. — The  urine  turns  red  on  adding  chloride  of  iron. 

Thallin. — The  urine  is  greenish-brown  and  turns  purple  on  adding 
iro"  chloride.  On  shaking  up  the  urine  with  ether,  the  unchanged 
thallin  is  also  taken  up  by  it  and  this  turns  green  on  adding  the  chlo- 
ride of  iron. 

Kairin. — The  urine  is  greenish  brown,  turns  dark  on  standing, 
and  turns  brownish-red  on  the  addition  of  the  chloride  of  iron. 

TuTpentine . — The  urine  smells  of  violets  and  a  precipitate  is 
sometimes  formed  on  adding  nitric  acid. 

Tannin. — The  urine  turns  bluish-black  on  the  addition  of  chloride 
of  iron. 

Santonin. — The  urine  is  straw -yellow  and  turns  scarlet  on  the  ad- 
dition of  alkalies. 

Rhubarb  and  Senna  (Chrysophanic  acid). — The  urine  turns  also  red 
on  the  addition  of  an  alkali,  but  the  color  remains  permanent, 
while  in  the  case  of  santonin  it  soon  disappears.  On  the  addition  of 
baryta  water  the  precipitate  with  rhubarb  and  senna  is  red,  and  with 
santonin  the  filtrate.  Ether  takes  up  the  color  of  senna  and  rhubarb, 
but  not  of  santonin. 

Organic  Sediments. 

Leucocytes  are  present  normally  in  a  small  number  in 
the  urine,  and  in  a  large  amount  in  inflammation  and 
suppuration  in  any  part  of  the  genito-urinary  apparatus 
(nephritis,  pyelitis,  cystitis,  gonorrhoea,  fluor  albus).  In 
alkaline  urine  the  pus  is  of  a  mucous  nature.  Red  blood 
corpuscles  in  the  urine  are  generally  free  from  color,  and 
in  renal  hemorrhage  are  often  in  the  casts. 

The  refial  epithelium  is  small,  round,  or  cuboid  with  a 
vesicular  nucleus,  and  often  very  full  of  fat  drops.  They 
are  often  arranged  in  cylindrical  form  or  lie  on  the  tube 
casts  adherent  to  them  (epithelial  casts).     The  appear- 


go  CLINICAL  DIAGNOSIS. 

ance  of  renal  epithelium  in  the  urine  always  points  to  a 

Fig.  32.       morbid  process  in  the  kidney.     When  there 

^  Ä^      ^^^    numerous    fatty    degenerated    epithelial 

^     ^''  ^^^'^  '^^  ^^  urine,  it  is  a  sign  of  chronic  par- 

^  v'»  '  enchymatous  nephritis. 

Sly  u^rSerloin"      Thc    epithelial  cells  of  the  bladder,  ureters, 

^  ^tiol?"^"^^    a7id  refial pelvis  do  not  differ  from  each  other 

in  appearance.     The  cells  of  the  superficial  layers  have 

a  polygonal  form,  those  of  the  deeper  layer  are  somewhat 

round,    often    with    processes 

(pear-shaped),   and  contain  a 

vesicular    nucleus.       If   there 

are  many  of  such   cells   with 

leucocytes  in  the  urine,  it  is  Deep 

evidence  of  an    inflammatory 


condition  of  the  bladder,  ure- 

.  1  1     •  rr-n  Epithelium  of  the  bladder, 

terS,      or       renal       pelvis.  Ihe  urethra,  and  renal  peU-is. 

microscopical  examination  is  of  no  assistance  here,  but 
we  can  generally  take  it  for  granted  that  the  urine  in 
pyelitis  is  generally  acid,  and  in  cystitis  generally  al- 
kaline. 

The  vagina  a.nd  prepz^ee  possess  very  long,  flat  epithelial 
cells  like  those  of  the  mucous  membrane  of  the  mouth. 
The  male  urethra  has  cylindrical  epithelium.  These 
epithelial  cells  are  often  found  in  the  suppuration  of 
acute  gonorrhoea.  The  gonorrhoeal  pus  is  also  charac- 
terized by  the  presence  of  gonococci  (see  Chapter  XI.). 

Casts  are  effusions  into  the  urinary  tubules.  They  are 
present  in  all  cases  of  albuminuria,  not  only  in  nephritis 
but  also  in  all  irritative  conditions  of  the  kidneys  (icterus, 
the  acute  contagious  diseases,  heart  diseases,  etc).  AVe 
distinguish  (i)  Hyaline  casts,  which  consist  of  a  homo- 
geneous translucent  substance,  and  possess  a  very  deli- 


THE    URINE-PRODUCING   SYSTEM.  9 1 

cate  contour,  which  is  often  scarcely  visible.  (2)  Granu- 
lar casts,  having  a  fine-grained  substance,  but  otherwise 
resembling  the  hyaline  casts.  (3)  Waxy  casts,  of  a  yel- 
low color  and  greater  lustre,  with  sharply-defined  contour, 
and  are  often  irregularly  curved  and  bent.  They  are 
found  principally  in  chronic  nephritis,  and  point  to  a 
grave  disturbance.  (4)  Brown  casts  are  present  in  frac- 
tures, and  also  in  the  grave  cases  of  contagious  diseases. 
(5)  Cylindrical  casts  are  long,  irregularly  broad,  with  long 
stripes  on  them.  These  are  perhaps  only  mucous  threads, 
and  are  of  no  diagnostic  importance.  Very  often  other 
substances  are  attached  to  the  casts,  especially  to  the 
hyaline  casts,  as  urates,  fat  drops,  red  blood  corpuscles, 
leucocytes,  and  renal  epithelium. 

Further,  there  are  found  occasionally  in  the  urine 
spermatozoa  and  cells  of  neoplasms  (cancer,  papilloma). 

Micro-organisms  are  present  in  fresh  urine  in  several 
of  the  contagious  diseases  (dii^htheria,  recurrent  fever), 
in  cystitis,  and  pyelonephritis  (in  a  cylindrical  form),  also 
tubercle  bacilli  in  tuberculosis  of  the  genito-urinary  tract 
and  gonococci  in  gonorrhoea. 

Animal  Parasites  : 

(i)  Echinococcus  cysts  and  booklets. 

(2)  Embryos  of  f^laria  sanguinis  :  small  snake-like 
worms  which  are  exceedingly  movable,  and  are  as  broad 
as  the  diameter  of  a  red  blood  corpuscle,  and  0.35  mm. 
[_|_  inch]  long. 

(3)  Distomum  haematobium  whose  eggs  have  on  one 
end  or  on  the  side  a  spinous  process.  The  two  last 
parasites  may  cause  haematuria  and  chyluria  {i\  Chapter 

XL). 

For  the  analysis  of  the  urinary  concrements  see 
Chapter  XIII. 


CHAPTER  X. 
TRANSUDATIONS  AND  EXUDATIONS. 

The  different  serous  transudations  have  a  very  different 
specific  gravity  according  to  their  origin.  They  are  in 
the  order  of  their  specific  gravity  ;  hydrocele,  hydro- 
thorax,  ascites,  anasarca,  and  hydrocephalus. 

The  serous  (inflammatory)  exudations  have  a  greater 
specific  gravity  than  the  simple  transudations  of  conges- 
tion, and  indeed  it  may  generally  be  taken  for  granted 
that  a  fluid,  be  its  origin  what  it  may,  is  the  product  of 
an  inflammation  when  its  specific  gravity  exceeds  1018 
(pleurisy,  peritonitis),  and  that  it  is  simply  a  transudation 
due  to  congestion  when  its  specific  gravity 

in    hydrothorax     is    less    than    1015, 
"    ascites  "      "         '-'■       1012, 

"    anasarca  "      "         '"        loio, 

"  hydrocephalus"  "  "  1008.5. 
Now  since  the  amount  of  ash,  extractive  matter,  etc., 
contained  in  exudations  and  transudations  varies  very 
slightly  and  the  amount  of  albumen  varies  very  greatly, 
we  conclude  that  the  specific  gravity  is  principally  de- 
pendent upon  the  amount  of  albumen  contained  in  these 
fluids.  Therefore  from  the  specific  gravity  the  amount 
of  albumen  may  be  approximately  determined  according 
to  the  formula  of  Reuss, 

E  —  I  (S  -  1000)  ~  2,8, 
93 


TRANSUDATIONS  AND   EXUDATIONS.  93 

in  which  E  denotes  the  amount  per  cent,  of  albumen 
sought  and  S  the  specific  gravity.  Accordingly  in  a  spe- 
cific gravity  of  1018,  3.95  (fo  of  albumen  would  be  calcu- 
lated. These  rules  hold  good  for  serous  exudations,  but 
not  for  purulent,  chylous,  and  very  hemorrhagic  exuda- 
tions, nor  for  those  in  diabetes,  cholaemia,  and  uraemia. 

In  order  to  determine  the  specific  gravity,  the  fluid 
should  be  protected  from  evaporation  and  cooled  off  to 
the  surrounding  temperature,  since  fluid  at  body  temper- 
ature has  too  low  a  specific  gravity  ;  for  every  3°  Celsius 
[5.4°  Fahrenheit]  increase  corresponds  to  about  one  de- 
gree of  the  araeometer  less. 

The  amount  of  albumen  is  determined  by  diluting  a 
known  quantity  of  the  exudation  (10  ccm.  \2\  drachms]  y 
with  ten  times  its  volume  of  water,  heating  it  to  the 
boiling  point  and  adding  dilute  acetic  acid  drop  by  drop 
until  the  fluid  is  slightly  acid.  The  precipitate  of  albu- 
men is  then  to  be  collected  upon  a  filter  paper  which  has 
previously  been  dried  at  a  temperature  of  100°  C.  [212° 
F.]  and  weighed,  washed  with  water,  then  with  alcohol 
and  ether,  the  total  weight  to  be  deducted  from  the 
weight  of  the  filter  paper.  The  filtrate  should  be  clear 
and  free  from  albumen,  which  may  be  proved  by  adding 
a  few  drops  of  ferrocyanide  of  potash  to  the  liquid. 

Exudations  and  transudations  have  an  alkaline  reac- 
tion, and  deposit,  en  standing,  a  more  or  less  abundant 
amount  of  fibrin.  A  microscopical  examination  reveals 
in  the  coagulum  leucocytes  and  swollen  endothelial  cells, 
which  often  contain  vacuoles. 

The  contents  of  the  echinococciis  cysts  are  generally  clear, 
neutral,  or  alkaline,  and  the   fluid  has  a  specific  gravity 

^  To  determine  the  amount  of  albumen  in  urine  50  or  100  ccm.  [i^— 
3  ounces]  of  urine  should  be  taken. 


94  CLINICAL   DIAGNOSIS. 

of  1008-1013,  contains  little  or  no  albumen,  but  chloride 
of  sodium  in  large  quantities,  as  well  as  grape  sugar  and 
succinic  acid.  The  latter  is  detected  by  evaporating  the 
fluid,  acidifying  it  with  hydrochloric  acid  and  shaking  it 
up  with  ether,  and  after  the  evaporation  of  the  ether  the 
succinic  acid  remains  as  a  crystalline  mass,  whose  water 
solution  with  the  chloride  of  iron  forms  a  gelatinous, 
rust-colored  precipitate  of  succinate  of  iron.  When 
heated  in  a  test-tube  the  irritating  fumes  of  the  succinic 
acid  are  given  off,  causing  cough. 

On  microscopic  examination  the  scolices  and  ring  of 
hooklets  are  sometimes  found.  In  the  older  lifeless  cysts 
are  found  crystals  of  Cholesterine  and  hsematoidine. 

The  water  of  hydronephrosis  is  generally  clear,  of  a 
specific  gravity  of  1010-1020,  contains  mucus,  sometimes 
blood  and  pus,  and  a  varying  amount  of  albumen  and  of 
urinary  constituents.  But  since  these  are  also  found  in 
the  fluid  of  the  echinococcus  the  diagnosis  of  hydro- 
nephrosis should  be  made  only  when  there  is  a  larger 
amount  of  urea  and  uric  acid  present.  Urea  is  detected 
according  to  the  method  on  page  70  ;  uric  acid,  by  adding 
muriatic  acid  and  examining  microscopically  the  crystals 
formed,  or  by  the  murexide  test. 

The  pear-shaped  epithelial  cells  of  the  renal  pelvis  and 
tube  casts  are  also  occasionally  present. 

The  contents  of  an  ovarian  cyst  are  generally  mucous, 
tenacious,  yellow  ;  but  may  be  watery,  semi-fluid,  and 
brown.  The  specific  gravity  is  between  1003  and  1055 
and  generally  between  loio  and  1024.  The  fluid  usually 
contains  albumen  and  metalbumen  (pseudo-albumen), 
which  causes  the  mucous  consistency.  This  is  not  pre- 
cipitated by  acetic  acid  (differing  in  this  respect  from 
mucin),  nor  by  heat,  nor  by  nitric   acid  ;  but  falls  into 


TRANSUDATIONS  AND  EXUDATIONS.  95 

fibrous  flakes  on  adding  alcohol.  By  heating  it  with  the 
mineral  acids,  a  reducing  substance  is  formed. 

To  detect  the  metalbumen  the  fluid  is  freed  from 
albumen  by  heat  and  acetic  acid.  When  metalbumen  is 
present  the  filtrate  is  opalescent  and  mucous.  It  is  pre- 
cipitated into  white  flakes  on  adding  alcohol  in  excess. 
The  flakes  are  then  pressed  out  and  heated  .with  dilute 
muriatic  acid  (5  (f)  until  they  turn  brown  ;  after  cooling 
off  they  are  made  alkaline  with  caustic  soda,  and  a  few 
drops  of  a  cupric  sulphate  solution  are  added  and  the 
whole  heated.  If  metalbumen  be  present  there  is  a  pre- 
cipitate of  yellow  cuprous  oxide. 

A  microscopic  examination  occasionally  shows  the 
presence  of  cylindrical  and  ciliated  epithelium,  and 
sometimes  colloid  particles. 


CHAPTER  XI. 

PARASITES. 

Animal  Parasites. 


Cestodes. —  The  tape-worms  represent  colonies  of  indi- 
viduals which  consist  of  a  head  with  hooklets  and  of  a 
larger  or  smaller  number  of  single  individuals  called 
proglottides  or  segments.  The  eggs  which  come  from 
the  matured  proglottides  (hermaphrodite),  if  they  come 
into  the  stomach  of  the  right  animal,  develop  in  its  or- 
gans into  a  Cysticercus.  If  this  Cysticercus  be  taken 
into  the  intestinal  canal,  it  becomes  a  tapeworm. 

Fig.  34.1  Fig.  35.  Fig.  36.  Fig.  37.  Fig.  38. 


Segment  of  Segment  of  Segments  of 

Taenia  solium.  Taenia  saginata.       Bothriocephalus 

latus. 


Egg  of 
Tcenia  solium. 


Egg  of 

Bothriocephalus 

latus. 


Tcenia  Solium  is  1-3  metres  [yards]  long.  The  head 
is  as  large  as  a  pin's  head,  has  four  suckers,  a  rostellum 
or  proboscis  upon  which  there  is  a  double  row  of  hooks. 

^  Figs.    34,  35  and   36  are   from  Stein's  Entwickelungsgeschichte 
und  Parasitismus  der  menschlichen  Cestoden. 

96 


PARASITES.  97 

The  matured  proglottides  have  the  sexual  openings 
on  the  side  and  a  uterus  with  7  to  lo  thick  lateral 
branches,  which  subdivide  (fig.  34).  The  eggs  are  round 
or  oval,  with  a  striped  shell  and  an  embryo  having  six 
hooks  (fig,  37).  The  Cysticercus  celliilosce  is  about  as  large 
as  a  pea,  and  is  found  in  swine  and  in  man  (when  the 
eggs  are  taken  into  the  stomach)  under  the  skin,  in  the 
muscles,  in  the  brain,  eye,  etc. 

Tcenia  saginata  or  mediocanellata  is  thicker  and 
larger  than  the  former.  It  has  a  head  with  four  suckers, 
but  no  rostellum  and  no  hooks.  The  proglottides  have 
lateral  sexual  organs  and  a  uterus  which  subdivides  into 
17  to  30  finer  branches  (fig.  35).  The  eggs  are  like  those 
of  the  taenia  solium,  only  somewhat  larger.  The  Cysti- 
cercus is  smaller,  and  is  found  in  the  flesh  of  cattle  (also 
in  deer  and  sheep). 

The  BotJu'iocephalus  latus  is  5-9  metres  [yards]  long, 
and  has  a  lancet-shaped  head  with  two  lateral  grooves. 
The  matured  segments  are  broader  than  they  are  long. 
The  uterus  has  a  brownish  tinge,  and  is  arranged  in  the 
form  of  a  rosette  around  the  flat  sexual  openings  (fig.  t,6). 
The  eggs  are  oval  and  have  a  cover.  The  cysticerci  are 
found  in  fish  (salmon). 

Taenia  nana,    taenia  flavopunctata  and  taenia  cucumerina  (elliptica) 
occur  sporadically  in  man. 

TcBnta  echijiococcus  is  found  in  the  dog.  It  is  2\  to  4 
mm.  [^j-g-  of  an  inch]  long,  has -a  head  with  booklets 
and  suckers,  and  three  segments,  of  which  the  last  one 
only  is  matured.  The  cystic  form  of  the  echinococcus  is 
found  in  man  (in  the  liver,  spleen,  kidneys,  lungs,  etc.). 
It  is  observed  in  two  forms,  as  a  large  echinococcus  sac 
filled  with  daughter  cysts,  and  as  an  echinococcus  multi- 


98 


CLINICAL  DIAGNOSIS. 


locularis,  which  consists  of  a  very  large  number  of 
minute  cavities  filled  with  a  gelatinous  substance  and 
with  concentrically  arranged  walls.  In  the  echinococcus 
cysts,  heads  (scolices)  with  hooks  are  sometimes  found. 
(For  the  echinococcus  fluid  see  page  93.) 

Nematodes  or  Round  Worms  are  bisexual. 

The  Ascaris  Itimbricoides  or  round  worm  has  its  habitat 
in  the  small  intestine.  It  resembles  the  rain  worm.  The 
male  is  somewhat  smaller  (150-250  mm.  [4-6  inches]) 
than  the  female  (150-250  mm.  [4-6  inches]  ),  and  its 
head  is  rolled  up.  The  eggs,  which  are  evacuated  in 
large  numbers  with  the  stools,  have  a  thick,  concentric- 


Fig.  40. 


Fig.  42. 


Egg'  of  Ascaris 
lumbricoides. 


EggofOxyuris    Egg  of  Trichocephalus    Egg  of  Ankylostomum 
vermicularis.  dispar.  duodenale. 


ally  striped  shell,  upon  which  lies  a  projecting  albuminous 
cover  (fig.  39). 

The  Oxyuris  vermicularis  or  small  thread-worm  is 
found  in  both  large  and  small  intestines.  It  often  passes 
from  the  intestine  to  the  anus,  causing  violent  itching  in 
that  region.  The  male  is  3-5  mm.  [-J-J  inch]  and  the 
female  10  mm.  [J-  inch]  long,  the  former  having  blunt 
ends,  and  the  latter  being  pointed.  The  eggs,  which  are 
especially  numerous  around  the  anus  of  man,  are  oval 
and  possess  a  thin  shell  (fig.  40). 

The  Trichocephalus  dispar  or  whip-worm  lives  in  the 
large  intestine  ;  it  is  4-5  cm.  \}\-2  inches]  long,  has  a 
thread-like  head  extremity,  and  a  thicker  spirally  rolled 
body  in  the  male,  and  a  straight  slightly  curved  body  in 


PARASITES.  99 

the  female.  The  eggs  are  yellow  in  color  and  shaped 
like  a  lemon  (fig.  41). 

The  Angiiillula  intestinalis  (Rhabdonema  strongyloides, 
Leuckart)  is  2.2  mm.  [i  inch]  long  and  lives  in  the  upper 
part  of  the  small  intestine.  The  eggs,  which  resemble 
those  of  the  ankylostomura  duodenale,  grow  in  the  intes- 
tine to  larvae  0.2  mm.  [-gL-  inch]  long  which  are  found  in 
the  fasces  as  small  worms  with  lively  movements.  Out- 
side of  the  body  the  latter  are  developed  to  an  interme- 
diate form,  the  anguillula  stercoralis.  This  belongs  to 
the  developmental  cyclus  of  the  anguillula  intestinalis. 

The  Ankylostomum  duodenale  lives  in  the  small  intestine, 
and  causes  anaemia  by  boring  into  the  intestinal  wall 
{e.  g.,  in  the  anaemia  of  the  St.  Gotthard  tunnel  work- 
men, brickmakers,  and  miners).  The  male  is  10  mm.  [^ 
inch]  long  and  the  female  12—18  mm.  [|— i  inch]  long. 
The  eggs,  which  are  passed  in  large  numbers  with  the 
stools,  have  clear,  simply  formed  shells  and  an  embryo 
which  is  generally  undergoing  fission  (fig.  42).  The  eggs 
are  developed  a  few  days  only,  after  the  passage  of  the 
larvae  from  the  intestines. 

The  Trichina  spij^alis  enters  the  intestine  through  trich- 
inosed  pork.  The  male  is  1.5  mm.  \^^  inch]  long  and 
the  female  3  mm.  [i-  inch]  long.  The  matured  worms 
live  in  the  small  intestine  and  bring  forth,  after  5-7  days, 
young  trichinae,  which  then  bore  through  the  intestinal 
walls,  get  into  the  circulation,  and  fix  themselves  in  the 
course  of  the  next  few  days  in  the  muscular  fibres,  where 
they  may  become  encapsuled.  Their  presence  at  first 
causes  fever. 

The  Filaria  sanguinis  is  found  in  the  tropical  regions.  It  causes 
hsematuria,  chyluria,  and  disturbances  of  the  lymph  circulation. 
The  matured  form  lives  in  the  lymphatic  organs  of  man,  and  here 


lOO  CLINICAL   DIAGNOSIS. 

gives  rise  to  a  large  number  of  living  embryos,  which  are  found 
in  the  urinary  sediment  and  blood,  and  indeed  in  the  latter  in  such 
large  quantities  that  ever}^  drop  of  blood  contains  several  embryos. 
These  appear  as  little  worms  which  move  freely,  and  are  surrounded 
by  a  delicate  envelop.  They  are  0.35  mm.  [yi^  inch]  long  and  as 
broad  as  the  diameter  of  a  red  blood  corpuscle. 

The  Filaria  medinensis  may  reach  80  cm.  \^o\  inches]  in  length 
and  |-i^  mm.  [äV^eV  inch]  in  breadth.  It  occurs  in  the  tropics,  and 
leads  to  the  formation  of  abscesses  of  the  skin. 

Trematodes  or  Flat  Worms. 

The  Disto7num  hepaticiwi  is  28-32  mm.  [i  inch]  long,  of 
a  leaf-like  form,  with  conical-shaped  forepart  of  the  body. 
The  eggs  are  very  large  0.13  mm.  [-gig-  inch]  long  (see  fig. 
43),  and  with  a  cover. 
Fig.  43,  Fig.  44.         The  Dist07num  la7iceolatui?i  is  small- 

er than  the  former.  It  may  reach 
9  mm.  ["I  inch]  in  length.  The  eggs 
are,  likewise,  considerably  smaller. 
Both  are  found  in  the  gall  bladder 
Egg  of  Egg  of      and  gall  ducts.     The  eggs  are  some- 

Distomum  Distomum 

hepaticum.  haematobium.    tlmCS  fOUnd  in   the   f^CCS. 

The  DistomujJi  JicEmatobium  occurs  in  the  tropics. 
It  lives  in  the  abdominal  veins,  and  causes  diarrhoea, 
haematuria,  and  chyluria.  The  male  is  12-14  nim.  [|- 
inch]  and  carries  in  a  groove  in  it  the  female,  which  is 
16-19  nim.  [-f-f  inch]  long.  The  eggs  are  0.12  mm.  \^-^ 
inch]  long,  are  found  in  the  urinary  sediment,  and  have 
a  point  either  at  one  pole  or  on  the  side  (fig.  44). 

Arthropodes. 

Acarus  (sarcoptes)  scabiei^  or  itch-insect  is  an  oval 
lenticular  body  with  eight  short  legs.  The  female  is 
found  at  the  end  of  the  furrow,  which  is  filled  with  the 


PARASITES.  lOr 

eggs  and  excreta  of  the  insect.  In  8  to  14  days  the 
young  ones  are  hatched,  and  in  turn  bore  into  the  skin. 

Acarus  (demodex)  folliculoriwi  is  longer  than  it  is 
broad,  and  is  found  in  comedones,  especially  in  the  face. 

Fediculus  capitis^  or  head  louse  ;  Pediculus  vestimenti, 
or  body  louse  ;  Pediculus  pubis,  or  crab  louse.  Pulex 
irritans,  or  flea. 

Protozoa. 

In.  the  stools  the  following  protozoa  are  sometimes  found  in 
chronic  diarrhoea  : 

Amceba  coll,  a  round  granular  structure  with  a  nucleus  and  a  few 
vacuoles.  Cercovionas  intestinalis,  pear-shaped  animalculae  (8-10  fx 
[g^y— 2^5  inch]  long),  with  ciliated  extremities.  Trichomonas  intesti- 
nalis (10—15  1^  [ä'^5~Tö  irich]  long),  almond-shaped  with  ciliated  ex- 
tremities. Balantidium  or  Paramceciuni  coli,  pear-shaped,  70-100 
ß  [i~3  inch]  long,  ciliated,  with  an  inverted  mouth.  Besides  these 
protozoa,  there  are  found  in  the  vaginal  secretion,  trichomonas  vagi- 
nalis, and  in  other  secretions  other  protozoa. 

Vegetable  Parasites. 

Hyphomycetes. 

Achorion  Schoeiileinii^  ox  fames  fungus,  is  in  the  shape 
of  worm-like  filaments,  which  are  provided  with  septa 
and  lateral  elevations,  and  in  their  ends  are  round  or 
oval,  brightly  shining  spores  (conidia). 

The  Trychophyton  tonsurans  is  the  fungus  of  herpes 
tonsurans  and  circinatus,  as  well  as  of  acne  mentagra 
(sycosis  parasitaria).  The  mycelium  consists  of  curved 
and  branching  filaments  provided  with  septa.  The  fila- 
ments have  partly  at  their  ends  shining  spores  (conidia) 
with  double  contour.  In  the  epidermis  the  fungus  fila- 
ments are  found,  while  in  the  hair  and  hair-sheath  the 
spores  (conidia)  are  found. 

The  Microsporon  furfur,  or  fungus  of  pityriasis  ver^ 


I02  CLINICAL   DIAGNOSIS. 

sicolor,  is  found  in  the  yellowish  epidermis  scales  in 
large  numbers  as  a  dense  network  of  curved,  more  or 
less  branched  filaments,  with  heaps  of  shining  spores 
(conidia)  within. 

The  Microsporo7i  minutissii?ium  is  a  very  fine  non- 
branching  filamentous  fungus  without  the  formation  of 
spores,  and  is  found  in  erythrasma,  but  whether  in 
causal  relation  or  not  is  doubtful. 

The  oidiiim  albicans^  or  thrush  fungus,  is  found  in  the 
mouth  cavity  as  well  as  in  the  oesophagus  and  the  stomach. 
It  consists  of  branching  filaments,  with  shining,  round  or 
oval  spores  (conidia)  at  the  points  of  bifurcation. 

The  Aspergillus  glaiictis  and  niger  are  often  found  in  the 
sputum  of  consumptives  or  imbeciles,  and  may  cause  a 
peculiar  kind  of  pneumonia  called  pneumonomycosis  as- 
pergillina  They  are  filaments  more  or  less  branched,  with 
double  contour  and  with  many  brown  pigmented  spores. 

In  order  to  make  the  filamentous  fungus  visible,  the  preparation 
(from  a  scraped  tongue,  epidermis  scales,  hair,  etc.)  is  allowed  to 
stand  for  a  few  minutes  in  a  lo  ;^  caustic  potash  solution,  which 
makes  the  albuminous  substances  and  epidermis  more  translucent, 
and  the  fungus  thereby  all  the  more  distinct. 

Yeast  fungi  are  frequently  found  in  fermenting  condi- 
tions of  the  stomach. 

Schizouiycetes  or  Bacteria. 

Morphologically  we  distinguish 

{a)  The  Coccus  (spherical  or  oval),  and  according  as 
the  cocci  are  single,  in  twos,  in  chains,  or  in  a  racemose 
conglomeration,  they  are  called  monococcus,  diplococcus, 
streptococcus,  and  staphylococcus. 

(}))  Bacillus  or  rod. 

{c)  Vibrio,  or  cwved  rod,  fragments  and  developing 
form  of  spirilla  as  comma  bacilli. 


PARASITES. 


103 


(^)  JLepfoihrix  foT^ms.     filiform. 
{e)   Spirillum.     Spiral  form. 

To  the  Cocci  belong  also  the  micro-organisms  of  erysipelas  (round 
streptococci)  and  of  puerperal  fever,  of  gonorrhoea  (bean-shaped  dip- 
lococci  which  are  found  in  clumps,  partly  in  the  leucocytes  of  the 
gonorrhoeal  pus),  of  croupous-  pneumonia  and  the  pus-producing 
cocci,  staphylococcus  pyogenes  aureus,  the  coccus  of  acute  osteo- 
myelitis, and  staphylococcus  pyogenes  albus,  etc. 

To  the  Bacilli  belong  the  micro-organisms  of  tuberculosis,  of  lepra 
(syphilis),  of  anthrax,  malleus  (glanders),  typhoid  fever,  diphtheria, 
malignant  oedema.  As  comma  bacilli,  are  to  be  mentioned  the  cholera 
bacillus  and  the  bacillus  of  Finkler-Prior. 

To  the  Spirilla  belong  the  Spirochaeta  Obermeieri,  in  recurrent 
fever,  and  the  Spirochaeta  buccalis  and  others. 


'M 


.®, 


^ 


Figs.  45-54- 


^^ 


Fig.  4S-  Fig.  46.  Fig.  47. 

Bacillus  mallei.    Bacterium  pneumoniae  Bacillus 

crouposse  tj^ihosus 

(Friedlaender).  (Eberth). 


/ 


^ 

^ 


i 


Fig.  50. 
Bacillus  anthracis. 


Fig.  51. 


'A 

Fig.  52. 


9 
Fig-  53- 


Fig.  49. 

Bacillus  tuberculosis 
(Koch). 


i^ 


Spirillum  or  spirochaeta    Bacillus  (s.  spiril-   Gonococcus 
Obermeieri  lum)  cholerse  Neisseri. 

(recurrent  fever).  asiaticse  (Koch). 


Fig.  54- 
Streptococcus 
erysipelatis. 


Clinically,  the  coloring  of  the  micro-organisms  in  a 
dried  preparation  is  almost  exclusively  used.  ^ 

*  The  preparation  and  the  staining  of  the  sections,  as  well  as  the 
methods  of  bacteria  culture,  are  subjects  too  extensive  to  be  taken 
up  here.  They  may  be  better  studied  in  the  "  Proceedings  of  the 
Royal  Board  of  Health"  (Berlin);  Cornil  et  Babes:  "  Les  Bac- 
teries  "  ;  Friedlaender  :  "  Microscopical  Technique  "  ;  Hueppe  : 
"  The  Methods  of  Bacterial  Investigation." 


I04  CLINICAL   DIAGNOSIS. 

A  small  drop  or  particle  of  the  substance  (blood,  pus, 
sputum,  tissue  juice,  etc.)  to  be  examined  is  spread  with 
a  platinum  needle  upon  a  clean  cover-glass,  or  two  glasses 
are  rubbed  together  so  that  a  thin  film  of  the  matter  is 
deposited  on  each.  The  cover-glasses  are  then  to  be 
protected  from  the  dust  and  left  until  dry.  Then  the 
glass,  with  the  preparation  side  turned  upward,  is  passed 
three  times  moderately  quickly  through  the  spirit  flame. 
Dry  preparations  of  blood  should  be  heated  a  few  hours 
at  a  temperature  above  ioo°  C.  (212°  F.),  in  order  to  fix 
the  haemoglobin,  and  the  best  way  to  accomplish  this, 
according  to  Ehrlich,  is  to  put  the  glass  on  a  metal  plate, 
to  one  corner  of  which  the  heat  is  applied.  The  dried 
preparation  may  then  be  colored. 

In  clinical  examinations  aniline  colors  are  principally 
used,  and  among  them  the  following  : 

{a)  The  acid  aniline  colors  :  Eosine,  picric  acid  (prin- 
cipally in  blood  examination). 

{h)  The  basic  aniline  colors  :  Fuchsin  (muriate  of 
rosaniline),  methyl  blue,  methyl  violet,  and  gentian  violet, 
vesuvin  (Bismarck  brown),  and  malachite  green. ^  Of 
these  colors  it  is  well  to  have  on  hand  either  a  concen- 
trated, watery  filtered  solution,  or,  what  is  better  in  the 
case  of  fuchsin,  a  concentrated  alcoholic  solution. 

The  coloring  of  the  dried  preparations  is  carried  out 
either  by  dropping  with  a  glass  rod  some  of  the  concen- 
trated watery  solution  on  the  preparation,  or,  if  the 
object  is  to  let  the  color  work  in  for  a  longer  time,  by 
letting  the  cover-glass  float,  with  the  preparation  down- 
ward, on  the  surface  of  the  staining  fluid  in  a  watch-glass. 
In  using  methyl  violet,  gentian  violet,  or  malachite  green 

^  These  colors  may  be  obtained  from  W,  König,  Berlin^  N,  W, 
Porotheenstrasse,  35, 


PARASITES.  105 

in  a  concentrated  watery  solution  i-i  minute  is  long 
enough  to  color  ;  in  the  case  of  fuchsin  and  methyl  blue 
it  is  well  to  use  more  diluted  solutions  for  several  minutes 
until  the  proper  tinge  is  obtained.  This  latter  has  the 
advantage  over  the  other  stains  in  not  over-coloring,  but 
in  staining  the  nuclei  and  bacteria  distinctly  and  causing 
no  precipitate  (Ehrlich).  Vesuvin  (Bismarck  brown) 
should  be  used  in  a  concentrated  watery  solution  for 
several  minutes. 

When  the  preparation  is  sufficiently  colored  it  should 
be  washed  off  carefully  with  water.  Then  the  cover-glass 
is  pressed  between  folds  of  filter  paper  and  finally  dried 
by  holding  it  over  the  flame,  and  then  examined  in 
Canada  balsam  (dissolved  in  turpentine)  or  in  cedar  oil. 

The  fundamental  principle  in  examining  stained  bac- 
teria preparation  is  to  remove  the  diaphragm  from  the 
microscope  stage,  and,  if  possible,  then  use  the  Abbe 
illuminating  apparatus  [condenser]  without  the  dia- 
phragm, making  the  contour  of  the  preparation  more 
indistinct,  and  thus  causing  the  colored  objects  to  be 
more  prominent.  But  in  all  other  microscopical  exami- 
nations in  which  the  endeavor  is  to  have  the  clearest 
possible  outline  in  an  uncolored  preparation — e.  g.,  in 
looking  for  hyaline  casts,  the  narrowest  diaphragm  ad- 
missible should  be  used. 

Almost  all  micro-organisms  except  the  tubercle  bacil- 
lus may  be  colored  in  dry  preparation  according  to  the 
above  methods. 

T/ie  staining  of  tubercle  bacilli  as  done  according  to  JEhr- 
lich.  Aniline  water  is  prepared  by  shaking  up  one  or 
more  ccm.  of  aniline  oil  with  20  ccm.  [5  drachms]  of  dis- 
stilled  w^ater,  and  allowing  it  to  stand  a  short  time,  and 
then  filtering.    To  the  clear  filtrate,  which  may  be  heated 


Io6  CLINICAL   DIAGNOSIS. 

to  boiling  in  a  test-tube  to  hasten  the  coloring,  5-10 
drops  of  a  concentrated  alcoholic  solution  of  diamond 
fuchsin  are  added  in  a  watch-glass  until  the  fluid  begins 
to  opalesce. 

Instead  of  this  solution,  which  should  be  prepared  fresh  every 
time,  the  following  of  Weigert-Koch  may  be  used,  which  can  be 
kept  10-12  days.  Saturated  aniline  water  100  ccm.  [3  ounces],  a  con- 
centrated alcoholic  solution  of  fuchsin  or  methyl  violet  1 1  com.  [2f 
drachms],  absolute  alcohol  10  ccm.  [2^^  drachms]. 

The  preparations,  smeared  on  a  cover-glass,  are  al- 
lowed to  float  on  the  solution  3-12  hours  (if  the  solution 
be  heated,  5—20  minutes  are  long  enough),  then  taken 
out  with  the  forceps,  dipped  for  a  few  seconds  into 
diluted  nitric  or  hydrochloric  acid  (1:3  water),  then  at 
once  thoroughly  washed  with  Avater.  If  the  preparations 
have  a  red  color  the  procedure  should  be  repeated  until 
this  color  disappears.  All  bacteria  are  decolorized  by  the 
acid  except  the  tubercle  bacillus  (and  lepra  bacillus). 
This  preparation  should  then  be  colored  by  a  drop  of 
concentrated  watery  solution  of  malachite  green  or 
methyl  blue,  again  washed  thoroughly  with  water,  dried, 
and  examined  in  cedar  oil  or  Canada  balsam.  The  tu- 
bercle bacilli  will  then  be  found  to  be  colored  red,  while 
every  thing  else  present  is  green  or  blue.  The  tubercle 
bacilli  may  be  recognized  with  a  power  of  350  diameters. 

The  isolated  method  of  staining  micro-organisms  accord- 
ing to  Gra?n.  The  preparations  are  first  colored  for  1-3 
minutes  in  a  solution  of  aniline  water  which  has  been 
saturated  with  gentian  violet,  and  then  put  into  a  solu- 
tion of  iodine  in  iodide  of  potash,^  and  then  in  absolute 


^  Iodine  i.o  [15  grains] 


lodme  1.0  [15  grams]. 

Iodide  of  potash  2.0  [30  grains]. 

Distilled  water  300.0  [gi  ounces]. 


PARASITES.  107 

alcohol  until  the  preparations  are  decolorized.  The  prep- 
aration is  then  to  be  stained  with  vesuvin  and  examined 
in  water,  or  dried  and  examined  in  cedar  oil  or  Canada 
balsam.     The  micro-organisms  are  colored  bluish  black. 

In  order  to  stain  the  pneumonococci  of  Friedländer, 
and  their  capsules,  there  may  be  made,  either  a  solution 
of  gentian  violet  in  aniline  water,  or  the  solution  which 
Ehrlich  uses  to  stain  the  plasma  cells. ^  The  preparation 
should  remain  twenty-four  hours  in  the  solution,  and 
then  put  in  i^  acetic  acid  for  a  few  minutes,  then  in 
alcohol,  turpentine,  and  Canada  balsam.  The  Lepra 
bacilli  are  colored  just  as  well  in  gentian  violet  or  methyl 
violet  as,  according  to  the  procedure  of  coloring,  the 
bacilli  of  tuberculosis.  The  micro-organisms  of  typhus, 
recu7'rent  fever,  glanders,  anthrax,  pymmia,  erysipelas,  etc., 
may  be  shown  with  any  of  the  basic  aniline  colors. 

To  color  the  gonococci,  a  drop  of  gonorrhoeal  pus  is 
pressed  between  two  cover-*glasses,  spread  out  to  a  thin 
film  upon  a  slide,  and  to  it  are  added  a  few  drops  of  a 
concentrated  watery  solution  of  methyl  blue,  which  is 
washed  off  in  a  half  minute,  and  then  dried  and  ex- 
amined  in  Canada  balsam  or  cedar  oil. 

The  actinomycosis  or  radiating  fungus,  whose  place 
among  the  micro-organisms  is  doubtful,  is  found  in  pus 
in  the  form  of  yellow-white  granules  of  the  size  of  a 
millet  seed,  which  consist  microscopically  of  a  large 
number  of  fine  radially  arranged  filaments,  which  end 
in  thick,  shining  knobs.  The  masses  of  actinomycosis 
are  often  calcified,  and  should  first  be  decalcified  with 
diluted  hydrochloric  acid.     Staining  is  superfluous. 

^  Concentrated  alcoholic  solution  of  gentian  violet,  50.0  [i^  ounces]. 
Glacial  acetic  acid,  lo.o  [2|-  drachms]. 
Distilled  water,  100. o  [3  ounces]. 


CHAPTER  XII. 

THE  NERVOUS  SYSTEM. 

Testing  the  Sensibility. 

We  distinguish  A?ic6sthesia,  a  loss  or  diminution  of 
sensation.  Hypercesthesia^  an  exaltation  of  the  same, 
weak  stimuli  causing  unpleasant  sensations.  ParcBsthe- 
sice,  or  abnormal  sensations  which  are  not  due  to  ex- 
ternal causes,  as  itching,  crawling,  formication,  furry- 
feeling,  abnormal  sensation  of  heat  and  cold.  NeuralgicB 
are  attacks  of  pain  which  are  confined  to  a  certain  nerve 
region,  and  they  generally  follow  the  course  of  the  nerve. 
They  are  generally  increased  by  pressure  on  the  nerve  on 
that  part  which  is  subcutaneous,  and  when  it  is  pressed 
against  a  bone  (pressure  point).  In  genuine  neuralgia 
the  pain  is  in  paroxysms. 

The  sensibility  may  be  equally  diminished  for  all  kinds 
of  sensation  or  for  some  kinds  only  (total  and  partial 
anaesthesia).     These  kinds  of  sensations  are  : 

Touch  seiise^  which  may  be  tested  by  delicately  touch- 
ing the  part  affected  with  the  finger-tip  or  any  other  ob- 
ject. The  patient,  whose  eyes  are  covered,  should  be 
very  attentive  to  note  the  slightest  touch.  The  test  may 
be  made  between  smooth  and  rough  (woollen)  objects. 
The  temperature  sense  must  then  be  excluded. 

The  se7ise  of  locality. — The  patient  should  be  touched, 

108 


THE  NERVOUS  SYSTEM. 


109 


I  mm.  \-^-^  inch]. 


and  then  asked  to  show  what  part  was  touched.  Healthy- 
individuals  rarely  miss,  or  err  by  1—2  cm.  [|— |-  inch]  only. 
Or,  by  using  a  pair  of  compasses,  the  smallest  distance 
may  be  found  in  which  the  two  points  applied  at  the 
same  time  and  in  the  same  way  can  be  recognized  as 
two  points.  The  distance  in  health  for  the  following 
localities  is  as  follows  : 

Tip  of  the  tongue 

Tip  of  the  finger  .... 

Red  surface  of  the  lips 

Dorsal  surface  of  the  first  and  sec- 
ond phalanx  and  inner  sur- 
face of  the  fingers 

Tip  of  the  nose     . 

Dorsal  and  palmar  surfaces 

Chin      ..... 

End  of  big  toe,  cheek,  and  eyelids 

Bridge  of  the  nose 

Heel 

Back  of  the  hand 

Neck 

Forearm,  leg,  dorsum  of  the  foot  .    40  mm.  [i  inch]. 

Back       ....     60-80  mm.  [i|-2  inches]. 

Upper  arm  and  thigh      .  .        80  mm.  [2 

Sense  of  pressure  (muscular  sense). — The  extremity  to 
be  tested  should  be  firmly  supported  and  weights  laid 
upon  it,  a  small  piece  of  board  being  put  between 
the  weight  and  the  extremity  to  eliminate  the  sense  of 
temperature.  Under  normal  conditions  a  difference  of 
■^-^  of  the  original  weight  can  be  recognized,  as  well  as  a 
minimum  pressure  of  0.002  to  i.o  gram  \^^  to  15  grains]. 
Greater  disturbances  of  the  muscular  sense  can  be  recog- 
nized by  pressure  with  the  finger. 


12 

13 

22 

30 

35 


[20 
[tV 


v\ 
[} 
[i 
ft 
ft 
[f 
[1 


]■ 


no  .    CLINICAL   DIAGNOSIS. 

Sense  of  temperature. — Test  tubes,  or  metal  vessels 
filled  with  water  of  different  temperature,  are  applied  to 
the  skin.  Between  25-35°  C.  [77-95°  F.]  a  difference 
of  1°  in  the  temperature  is  recognized  by  a  healthy  per- 
son. The  test  may  be  made  by  letting  the  patient  en- 
deavor to'  distinguish  between  warm  breath  near  the  skin 
and  cold  breath  from  a  distance.  Many  patients  will  say 
that  the  irritation  from  the  cold  (ice)  is  hot,  and  vice 
versa  (perverted  temperature-sense). 

Electro-cutaneous  sensibility.  —  By  applying  a  metal 
brush  to  the  skin,  it  may  be  ascertained  with  what 
strength  of  current  (distance  of  the  coils)  the  faradic 
stream  has  been  felt. 

Sensibility  to  pain  is  tested  by  sticking  with  a  needle, 
pinching,  pulling  the  hair,  and  using  strong  electric  cur- 
rent. If  strong  and  painful  irritation,  as  deep  puncture 
with  a  needle,  be  felt  as  if  the  needle  only  touched  the 
skin,  without  pain,  then  it  is  called  analgesia.  Analgesia 
occurs  with  unimpaired  tactile  sense  in  hysteria  and 
tabes.  Also  the  reverse  may  be  noticed,  /.  e.,  simple 
contact  may  cause  pain.  There  is  often  a  delay  experi- 
enced in  the  transmission  of  the  sensation  of  pain,  or  an 
abnormal  after-sensation,  and,  at  times,  the  tactile  and 
pain-producing  sensations  are  separated  and  are  per- 
ceived one  after  the  other  (a  double  sensation). 

The  sejisitiveness  of  the  deep  parts — the  muscles,  fascia, 
tendons,  ligaments,  joints,  periosteum,  and  bones — is 
classed  as  follows  : 

I.  The  ability  to  judge  of  the  weight  of  a  body  when 
raised  up,  i.  e.,  the  sense  of  force  ;  this  is  tested  by  lifting 
up  a  cloth  to  which  weights  are  gradually  added,  and  es- 
timating the  weight.  The  sense  of  force  is  finer  than  the 
sense  of  pressure. 


THE  NERVOUS  SYSTEM.  Ill 

2.  The  ability  to  judge,  with  closed  eyes,  of  the  position 
of  one's  extremities  and  their  passive  movements  ;  or  it 
may  be  tested  by  letting  the  patient  close  his  eyes  and 
attempt  to  touch  one  extremity  with  the  other  ;  or, 
further,  the  power  to  hold  the  body  in  an  upright  position 
when  the  eyes  are  closed.  If  the  patient  stand  firm  with 
open  eyes,  and  totter  or  fall  when  the  eyes  are  closed 
(symptom  of  Romberg),  then  the  sensibility  of  the  limb 
is  diminished. 

Testing  the  Motility. 

When  the  power  of  voluntary  motion  in  a  muscle  is 
completely  lost,  we  speak  of  paralysis^  and  when  this  is 
only  weakened,  of  pat-esis.  According  to  the  extent  of 
the  paralysis,  we  speak  of  a  monoplegia  or  paralysis  of 
single  muscles  or  group  of  muscles,  or  of  an  extremity 
by  itself  ;  hemiplegia,  paralysis  of  one  side  ;  paraplegia, 
paralysis  of  corresponding  parts  of  both  sides  of  the 
body,  /.  e.,  of  both  limbs,  or  of  both  arms,  or  of  all  four 
extremities. 

It  should  be  noticed  whether  the  state  of  muscular 
tension  deviates  from  the  normal  or  not.  In  diminished 
tension  the  paralyzed  muscles  are  relaxed,  and  make  no 
opposition  to  passive  movements.  This  relaxed  paralysis 
occurs  principally  in  peripheral  lesions  in  diseased  con- 
ditions of  the  anterior  gray  horns  or  gray  nuclei,  as  in 
infantile  paralysis. 

In  iiicreased  tension  the  muscles  are  stiff,  rigid,  and 
oppose  all  passive  movements.  If  the  tension  is  in- 
creased, it  may  lead  to  contraction.  The  rigid,  so-called 
spastic  paralysis  presupposes  a  central  lesion  (of  the 
brain  or  spinal  cord),  and  occurs  principally  in  degenera- 
tion of  the  lateral  pyramidal  tracts  of  the  spinal  cord, 


112  CLINICAL   DIAGNOSIS. 

in  spastic  spinal  paralysis,  in  amyotrophic  lateral  scle- 
rosis, in  cerebral  apoplexy  or  embolisms,  etc.  Spastic 
paralysis  goes  hand  in  hand  with  an  exaggerated  tendon 
reflex^  while  in  relaxed  paralysis  there  is  a  diminution  or 
absence  of  the  tendon  reflex. 

In  contradistinction  to  the  orgajiic  paralyses,  in  which 
the  motor  tract  in  any  part  is  injured,  we  speak  of  a 
fu?ictiona I  ^dLidily SIS,  where  the  motor  tract  is  unimpaired, 
i.  e.,  in  hysterical  paralysis. 

Ataxia  means  the  inability,  with  intact  power,  to  coor- 
dinate the  separate  muscles  to  a  certain  action — that  is, 
a  condition  in  which  the  patient  makes  clumsy  motions, 
when  he  was  previously  skilful.  He  is  asked  to  quickly 
reach  for  a  certain  object,  to  button  a  button,  to  write, 
to  walk  a  straight  line,  to  turn  himself  around,  to  describe 
a  circle  with  the  foot,  etc.  The  patient  shows  ataxia 
when  on  the  feet,  by  standing  with  the  feet  wide  apart, 
and  walking  stiff-legged  or  stamping  along.  When  the 
patient  cannot  control  his  movements  with  his  eyes  (in 
the  dark,  and  with  closed  eyes),  the  ataxia  is  generally 
worse.  Ataxia  occurs  in  diseases  of  the  spinal  cord 
(tabes),  as  well  as  of  the  brain  and  peripheral  nerves 
(cerebellar,  alcoholic,  diphtheritic  ataxia). 

Motor  Symptoms  of  Irritation. 

Spasms^  or  involuntary  muscular  movements,  are 
divided  into  clonic  (interrupted  quiverings  of  short  dura- 
tion), and  tonic  (contractions  of  longer  duration).  If  the 
tonic  spasms  extend  to  most  of  the  muscles,  it  is  called 
tetanus.  Convulsions  are  numerous  quick,  powerful 
clonic  spasms,  especially  if  they  extend  over  the  whole 
body. 

Trernoj's  occur  either  in  muscles  at  rest   (in  paralysis 


THE  NERVOUS  ST  STEM.  II3 

agitans),  or  in  muscles  voluntarily  moved,  especially  in 
the  movements  which  demand  strength  or  precision 
(tremor  of  intention  as  in  multiple  sclerosis).  Trembling 
of  the  eyes  is  called  fiystagmiLS  (multiple  sclerosis). 

Choreic  piove7ne?its  are  quick,  involuntary,  and  incoordi- 
nate movements  which  interrupt  and  prevent  the  volun- 
tary motion.  They  occur  in  chorea  minor,  and  at  times, 
on  one  side  after  (or  before)  hemiplegia. 

Further,  the  following  are  to  be  mentioned  :  Compul- 
sory movements  (riding  motion),  accompanying  motions 
(generally  central),  athetosis  motions  (slow  and  rhythmic 
exaggerated  movements  of  the  hands),  and  cataleptic 
(waxy)  muscular  rigidity. 

Diagnosis  by  Means  of  Electricity. 

The  test  should  be  made  both  with  the  faradic  (inter- 
rupted) and  galvatiic  (constant)  current,  both  by  direct 
application  to  the  muscles,  or  by  indirect  excitation  of 
the  muscles  through  the  nerves.  The  indifferent  \i.  e., 
non-active]  pole  (a  long,  flat  electrode)  is  placed  on  the 
sternum,  and  the  other,  different  [i.  e.,  active]  pole,  on 
the  nerve  or  muscle  to  be  examined.  A  small,  button- 
shaped  electrode  serves  for  the  different  pole,  since 
it  must  be  taken  into  account,  for  the  effect  of  the 
electrical  excitation,  that  the  current  reach  the  part  to 
be  excited,  with  the  greatest  density.  The  density  (D)  is 
greater  in  proportion  as  the  intensity  (I)  of  the  current  is 
greater,  and  the  section  of  the  conductor  (S)  is  smaller  at 
the  spot  :    D  =  g. 

The  electrodes,  as  well  as  the  skin  of  the  patient, 
should  be  well  moistened  with  warm  water.  The  situa- 
tion of  the  points  in  which  a  muscle   or  nerve   may    be 


114 


CLINICAL   DIAGNOSIS, 


excited,  is  shown  in  the  accompanying  illustrations.^ 
By  gradually  increasing  the  strength  of  the  current,  we 
arrive  at  a  point  where  the  first  minimum  muscular  con- 
traction takes  place. 

The   examination   is  begun   with   the   faradic   current 
and   generally   with   the   current   of  the  secondary   coil. 

.     Fig.  55. 


Region  of  central 
convolutions. 

Region  of  third 
frontal  convolu- 
tion and  island 
of  Reil. 

M.  temporalis. 


N. 


f  U. branch. 
J  M.branch. 
facial.   I  Trunk. 

'^L.  branch. 
N.  auricular  post. 

M.  splenius  capitis. 

M   sternocleido- 
mastoid. 

N.  accessor  Wil- 
lisii. 

M.  cucullaris. 
N.  dors,  scapulae. 

N.  axillaris. 

N.  thoracic,  long. 
(M.  serratus  ami- 
cus.) 

N.  phrenicus. 
Plexus  brachialis. 


M.  frontalis. 

M.  corrug.  super- 
cil. 

M.  orbicular,  pal- 
pebr. 

M.  levator  labii 
super.  alaeque 
nasi. 

Mm.  zygomatic!. 

M.  orbicular,  oris. 
M.  masseter. 

M.  levator  menti. 

M.  quadrat,  men- 
ti. 
M.triangul. menti. 

N.  liypoglossus. 

Platysma 

myoides. 

Muscles  of  hyoid 
bone. 


N.  thoracicus  an- 
terior (M.  pecto- 
ral major.) 

Supraclavicular  point  of  Erb  (Mm.  deltoideus,  biceps,  brachial,  intern,  [anticus], 
supinator  longus  etbrevis,  infraspinatus  et  subscapularis). 

As  a  standard  of  measurement  of  the  intensity  of  the 
current,  the  distance  between  the  coils  (R.  A.)  is  ex- 
pressed in  millimetres,  and  the  current  is  stronger  in  pro- 
portion as  the  coils  2.xq  further  apart. 

^  These  are  drawn  from  the  illustrations  in  the  text-books  of  Ziems- 
sen,  Erb,  Bernhardt,  Rosenthal  and  Eichhorst.  For  details  as  to 
plectro-diagnosis,  as  well  as  electro-therapeutics,  see  these  books. 


THE  NERVOUS  SYSTEM.  1 15 

Also  the  faradic  current  must  be  graded  by  moving 
the  iron  rod  (in  the  coil)  ;  for  the  current  is  so  much  the 
stronger  in  proportion  as  the  rod  is  pushed  further  into 
the  primary  spiral. 

In  using  the  galvanic  current^  the  cathode^  (negative 
zinc  pole)  is  applied  to  the  muscle  or  nerve  to  be  examined. 
By  gradually  increasing  the  strength  of  the  current,  it 
may  be  determined  what  the  least  intensity  is,  with 
which,  at  the  closing  of  the  current,  a  contraction  takes 
place  (cathodal  closing  contraction,  KaSZ^).  The  in- 
tensity is  noted  by  giving  the  number  of  elements  used, 
or  by  reading  off  the  number  on  the  galvanometer. 

Then  the  current  is  used  unclosed,  with  the  commuta- 
tor, (from  N,  the  normal  position,  to  VV,  change),  by 
which  the  exciting  electrode  becomes  the  anode  (the 
positive,  carbon,  or  copper  pole),  and  determines  the 
minimum  of  contraction  on  closing  (anodal  closing  con- 
traction, AnSZ)  and  on  opening  (anodal  opening  con- 
traction,  AnOZ).     The    closing    and    opening    of    the 


'  In  filling  the  carbon  zinc  elements,  the  following -fluid  is  used  : 
Bichromate  of  potash,  70.0  [17^  drachms]. 
Water,  900.0  [28  ounces]. 

Concentrated  sulphuric  acid,  170.0  [5|  ounces.] 
Sulphate  of  mercury,  10. o  [2^  drachms]. 
The  last  ingredient  is  to  keep  the  zinc  amalgamated. 
'In  order  to    distinguish  the    two    poles,    the    ends  of   the  wire 
should  be  immersed  in  a  solution  of  iodide  of  potash  and  starch,  and 
blue  clouds,    due    to  the  free  iodine  and  starch,  are  formed  at  the 
anode.     Or  the  ends  of  the  wires  may  be  dipped  in  water,  and  the 
bubbles  of  hydrogen  will  show  which  is  cathode,  while  the  anode  is 
recognized  by  the  absence  of  bubbles,  due  to  the  rapid  oxidation  of 
the  oxygen  as  fast  as  it  is  formed. 

•^  [For  the  sake  of  uniformity,  the  German  abbreviations  are  used 
throughout.] 


Il6  CLINICAL   DIAGNOSIS. 

current  should  be  effected  by  the  interrupter  without 
changing  the  position  of  the  electrodes. 

Under  normal  conditions,  the  results  of  the  irritation, 
on  gradually  increasing  the  intensity  of  the  current,  are 
in  the  following  order  : — 

(i)  Cathodal  closing  contraction,  KaSZ. 

(2)  Anodal  opening  contraction,  AnOZ. 

(3)  Anodal  closing  contraction,  AnSZ. 

(4)  Cathodal  closing  tetanus,  KaOZ  (lasting  contrac- 
tion with  KaS). 

(5)  Cathodal  opening  contraction,  KaOZ, 

This  law  holds  good,  however,  only  in  indirect  irrita- 
tion of  the  nerves.  In  direct  application  of  the  electrode 
to  the  muscle,  there  are  generally  closing  contractions, 
and  AnSZ  may  be  equal  to  KSZ  or  even  greater  than  it. 

The  contractions  are  short,  quick,  and  may  be  excited 
through  the  nerve  or  muscle. 

The  intensity  of  the  current  is  expressed  by  the  num- 
ber of  elements  used,  or  still  better,  when  an  absolute 
galvanometer  is  at  hand,  in  milliamperes. 

According  to  Ohm's  law  I  z=  ^  ;  that  is,  the  strength  of 
the  current  or  intensity  (I)  is  in  proportion  to  the  electro- 
motive force  (E,  number  of  elements),  and  is  in  inverse 
proportion  to  the  whole  amount  of  the  resistance  pres- 
ent in  the  electric  current.  Now  an  ampere  is  that 
strength  of  current  (I)  which  is  generated  by  the  electro- 
motive force  (E)  of  i  volt  in  an  electric  current  of  re- 
sistance (W),  of  I  ohm.  An  ampere  then,  is  equal  to 
^-^ .     One  volt  is  equal  to  ^-V  of  the  electromotive  force 

I  ohm  ^  1  U 

of  a  Daniell  element  ;  one  ohm  is  equal  to  a  column  of 
mercury  106  cm.  long,  and  i  square  millimetre  in  section 
(1.06  Siemen's  unit).  For  medical  purposes,  no  strength  of 
current   higher  than   20  thousandth   (milli-)  amperes   is 


THE  NERVOUS  SYSTEM.  1 17 

used.      With    motor  nerves   superficially  situated  KaSZ 
occurs  normally  with  currents  of  1-3  MA  strength. 

The  strength  of  the  current  may  be  varied,  either  by 
inserting  more  or  less  elements,  or  by  means  of  a  rheo- 
stat, by  which  resistance  of  different  degrees  may  be 
inserted  into  the  current. 

The  resistance  in  the  dry  epidermis  is  at  first  very  great,  but  after 
using  the  galvanic  current  for  some  time,  and  thoroughly  moistening 
the  skin,  the  resistance  is  considerably  diminished,  so  that  by  using 
a  current  of  medium  strength  with  the  number  of  elements  (E),  re- 
maining the  same,  the  strength  of  the  current  (I)  increases  to  a 
certain  point.  A  current  which  is  not  felt  at  the  beginning  of  the 
examination,  and  causes  no  contraction,  may,  by  keeping  the  current 
closed,  and  diminishing  the  resistance  without  changing  the  number 
of  elements,  so  increase  as  to  become  painful  and  cause  evident 
contraction. 

Quajititative  changes  in  the  electro-irritability,  that  is 
simple  increase  or  diminution,  are  judged  by  comparing 
both  sides  of  the  body  (in  unilateral  affections),  and  by 
testing  analogous  points  which  have  approximately  the 
same  irritability  in  health,  e.  g.,  the  frontal  nerve,  the 
spinal  accessory  in  the  neck,  the  ulnar  nerve  above  the 
olecranon,  and  the  peroneal  nerve  between  the  bend  of 
the  knee  and  the  head  of  the  fibula  (Erb).  Here  it 
should  not  be  forgotten  that  the  conductive  resistance  of 
the  skin  is  different  in  different  parts  of  the  body,  and 
in  different  individuals. 

Simple  increase  of  electric  irritability  occurs  in  tetanus,  and  a 
simple  diminution  of  electric  irritability  may  develop  in  all  paralyses 
of  long  duration,  which  begin  with  simple  non-degenerative  muscu- 
lar atrophy,  e.  g.,  after  apoplexy  and  muscular  atrophy  of  the  joint 
troubles. 

When  there  is  a  very  great  diminution  of  the  electric  irritability, 
a  contraction  may   be  caused,    with    the    strongest    currents,    with 


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o 

a 

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D 

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D 

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a 

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SS 


5.5      S  =       -=      5 


t  — 

s   s    s 


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Nervus  cruralis. 


Nervus  tibialis. 


tJO 


Nervus  obcuratorius. 


Nervus  peroaeus. 


Nervus  tibialis. 


IIQ 


I20  CLINICAL   DIAGNOSIS, 

closed  connection  only,  from  the  anode  to  the  cathode  (Volta's  alter- 
native), and  even  this  may  be  entirely  extinguished. 

A  qualitative  change  in  the  electric  irritability,  is  called 
the  rcaciio7i  of  degenei-ation  (EaR).  When  a  motor 
nerve  is  diseased  or  cut  off  peripherally  from  its  trophic 
centre  (the  anterior  horns  of  the  spinal  cord,  or  the  gray 
matter  of  the  cervical  nerves),  or  if  the  trophic  centre 
itself  be  diseased,  a  motor  paralysis  appears,  the  nerve 
becomes  degenerated,  and  the  degeneration  (degenera- 
tive atrophy)  reaches  to  the  muscle  supplied  by  it.  The 
electric  irritability  of  the  nerve  diminishes  for  the  fara- 
dic,  as  well  as  for  the  galvanic  current,  and  is  destroyed 
after  about  two  weeks,  /.  ^.,  the  nerve  ceases  to  conduct 
the  electric  current  as  well  as  the  will.  Also  the  direct 
faradic  irritability  of  the  muscle  is  diminished  and  dis- 
appears ;  on  the  contrary,  in  the  2d  or  3d  week  there  is 
an  increase  of  the  dii'cct  muscular  irritability  for  the 
galvanic  current,  the  contractions  occur  with  the  weak- 
est current,  but  are  long  drawn  out  a7id  slow,  and  the 
formula  of  contraction  is  changed.  The  AnSZ  occurs 
with  the  same  or  weaker  current,  as  the  KaSZ,  and  the 
KaOZ  becomes  like  the  AnOZ.  In  one  or  two  months 
the  galvano-muscular  irritability  diminishes,  and  disap- 
pears in  a  few  months.  If  recovery  take  place  the 
muscular  tonus  and  voluntary  motion  appear,  but  the 
electric  irritability  returns  only  gradually  to  the  normal. 

This  "  complete  reaction  of  degeneration  "  only  occurs 
in  grave  lesion  of  the  nerves  (transverse  rupture,  se- 
vere rheumatic  facial  paralysis);  when  the  conditions  of 
degeneration  are  not  so  grave,  there  is  often  an  incom- 
plete, or  even  no  "partial  reaction  of  degeneration."  In 
the  latter  case,  the  irritability  for  the  nerves  is  retained, 
and  also  the  direct  faradic  muscular  irritability.     In  di- 


THE   NERVOUS  SYSTEM.  121 

rect  galvanic  irritation  of  the  muscles,  there  are  neverthe- 
less, hyperexcitability,  and  change  of  the  formula  of 
contraction  (AnSZ  >  KSZ),  and  a  sloiu  contraction. 
The  latter  is  the  actual  characteristic  of  EaR, 

The  reaction  of  degeneration  is  present  in  peripheral  lesions  of  the 
motor  nerves,  of  a  traumatic,  rheumatic,  neurotic,  or  diphtheritic 
nature,  also  in  disease  of  the  gray  matter  of  the  anterior  horns  of 
the  spinal  cord,  and  of  the  gray  nuclei  of  the  medulla,  e.g.^  in  in- 
fantile paralysis  and  lead  paralysis  ;  also  sometimes  in  progressive 
muscular  atrophy,  bulbar  paralysis,  amyotrophic  lateral  sclerosis, 
myelitis,  etc. 

The  EaR  is  absent,  however,  in  all  cerebral  paralyses  (apoplexies), 
and  in  those  spinal  paralyses  which  have  a  central  cause  from  the 
trophic  centre,  and  also  in  pure  myopathic  paralysis  (pseudo-hyper- 
trophy of  the  muscles). 

The  trophic  behavior  of  the  paralyzed  muscles  is  en- 
tirely analogous  to  the  electric  behavior.  In  disease  of 
the  gray  matter  of  the  anterior  horns,  as  well  as  in  lesions 
of  the  motor  nerves  peripherally  from  themselves,  a 
degenerative  atrophy  occurs,  while  in  paralysis  whose 
cause  lies  in  the  motor  tract  central  from  the  gray  mat- 
ter of  the  anterior  horns,  a  slight  atrophy  of  the  para- 
lyzed muscle  takes  place,  but  not  until  after  a  long  time 
(atrophy  of  inactivity). 

In  degenerative  atrophy  of  the  muscles,  there  are  often 
fibrillary  contractions  observed  in  them. 

Reflexes. 

We  distinguish  skin  (superficial)  and  tendon  (deep) 
reflexes.  It  is  not  certain  whether  the  latter  are  actually 
reflex  or  not.  They  do  not  behave  alike,  and  may  be 
often  completely  different. 

Among  the  skin  reflexes  which  are  more  or  less 
present  in  health,  are  : 


122  CLINICAL   DIAGNOSIS. 

Reflex  of  the  sole  of  the  foot :  In  exciting  the  sole  of 
the  foot  by  tickling,  stroking,  sticking,  touching  it  with 
ice,  there  is  dorsal  flexion  of  the  foot,  and  when  the  irri- 
tation is  strong,  the  leg  is  drawn  up  against  the  body. 

Cre??iaster  reflex :  In  exciting  the  inner  surface  of  the 
thigh,  the  corresponding  testicle  rises  up. 

Reflex  of  the  abdominal  walls,  gluteal  and  scapular  re- 
gions :  In  irritating  the  skin  in  these  regions,  the  corre- 
sponding muscles  contract. 

Tendon  Reflexes. 

Patellar  reflex :  If  the  patellar  tendon  be  percussed 
while  the  leg  is  crossed  and  co??ipletely  relaxed,  and  the 
patient's  attention  be  withdrawn,  there  is  a  contraction  of 
the  quadriceps  and  the  leg  is  extended. 

Patellar  clonus  :  If  the  patella  be  pushed  quickly  down 
and  held  there  firmly,  there  is  a  rhythmic  contraction 
of  the  quadriceps. 

Reflex  of  the  te?ido  Achillis  :  In  percussing  the  tendo 
Achillis,  there  is  caused  a  contraction  of  the  calf  muscles. 

Foot  clonus  :  If  the  foot  be  seized  by  the  ball  of  the 
great  toe,  and  be  pressed  quickly  upward  while  the  knee 
is  slightly  bent,  there  is  a  rhythmic  plantar-contraction 
of  the  calf  muscles. 

In  health  the-  patellar  reflex  is  constant,  and  the  reflex 
of  the  tendo  Achillis  frequent.  The  presence  of  the 
remaining  tendon  reflexes,  also  of  the  upper  extremities 
(biceps,  triceps,  flexors  of  the  hand  etc.),  is  considered 
as  a  diseased  reflex  irritability. 

In  order  that  the  conditions  of  reflex  tendon  may  occur, 
it  is,  above  all  things,  necessary  that  the  reflex  circtiitho. 
entire.  This  reflex  circuit  is  formed  by  the  sensory 
nerve  tracts,  which  go  from  the  muscle  or  tendon  or  fas- 


THE  NERVOUS  SYSTEM.  123 

cia,  to  the  spinal  cord  and  motor  tracts  which  descend  to 
the  muscles,  as  well  as  to  that  part  of  the  spinal  cord 
connecting  both.  The  reflexes  are  extinguished  when  the 
reflex  circuit  is  interrupted  in  any  part  of  its  course,  /.  e.^ 
when  the  centripedal  or  centrifugal  nerves,  or  their  con- 
nection with  the  spinal  cord  (Burdach's  pyramidal  gray 
substance),  are  injured.  The  reflexes  are  increased  \N\\Q'i\ 
these  nerves  are  in  an  abnormally  excited  condition,  or 
when  the  inhibitory  fibres  are  interrupted  in  their  course 
from  the  cerebrum  through  the  lateral  tracts  to  the  reflex 
circuit. 

The  tendon  reflex  is  extinguished  in  polyomyelitis  anterior  (infan- 
tile paralysis),  tabes  dorsalis,  peripheral  nerve  lesions,  and  diffuse 
myelitis.  Increase  of  the  tendon  reflex  is  observed  in  sclerosis  of 
the  lateral  tracts,  in  amyotrophic  lateral  sclerosis,  in  hemiplegia  with 
contraction,  in  multiple  sclerosis,  division  of  the  spinal  cord  above 
the  reflex  circuit,  and  further  in  dementia  paralytica  and  hysteria, 

Paradox  contraction  (Westphal)  :  When  the  foot  of  the 
recumbent  patient  is  quickly  and  firmly  flexed,  there  is 
sometimes  a  contraction  of  the  tibialis  anticus,  its  ten- 
don is  prominent,  and  the  foot  remains  for  a  short  time 
in  this  position  after  it  has  been  let  go. 

Among  the  reflex  functions  may  be  mentioned  the 
passing  of  urine  and  faeces,  the  sexual  reflex  and  pupil 
reflex. 

The  pupil  is  supplied  with  fibres  from  the  oculomo- 
torius  for  the  sphincter  pupillse  as  well  as  those  from 
the  sympathetic  for  the  dilatator.  A  centre  for  the 
pupil  reflex  lies  in  the  lower  cervical  region  (cilio-spinal 
centre).  Irritation  of  the  sympathetic  fibres  coming  from 
the  centre,  causes  dilatation  of  the  pupil  (mydriasis  spas- 
tica), paralysis  of  the  same,  a  narrowing  of  the  pupil 
(myosis  paralytica).     Irritation  of  the  oculomotorius,  on 


124  CLINICAL   DIAGNOSIS. 

the  contrary,  causes  narrowing  of  the  pupil,  and  paraly- 
sis of  it,  dilatation,  and  want  of  reflex  for  light  as  well  as 
for  accommodation  to  near  objects.  Reflex  rigidity  of 
the  pupil  for  light,  with  retained  movement  for  accom- 
modation for  near  objects,  occurs  with  narrowing  and 
inequality  of  the  pupils,  most  frequently  in  tabes  dorsalis 
and  dementia  paralytica. 

The    Most    Important    Clinical    Points    in    the 
Anatomy  of  the   Nervous   System. 

Brain  and  Spinal  Cord. — The  psychomotor  region  of 
the  cerebral  cortex  is  formed  by  the  two  central  convo- 
lutions and  their  connecting  part  on  the  median  surface, 
the  lobus  paracentralis.  The  centre  for  the  leg  probably 
lies  in  the  latter  and  in  the  two  upper  thirds  of  both  the 
central  convolutions  ;  and  in  the  middle  third  of  the  an- 
terior convolution  lies  the  centre  for  the  arm  ;  and  in  the 
lower  third  of  the  anterior  convolution,  the  centre  for  the 
face  (facialis,  hypoglossus).  Bordering  on  the  latter,  and 
in  the  posterior  portion  of  the  third  left  lower  frontal  con- 
volution, as  well  as  in  the  island  of  Reil,  lies  the  centre  for 
speech.  When  this  is  injured,  aphasia  occurs.  The  cortex 
of  the  parietal  lobes  is  brought  into  relation  with  the  sensi- 
ble tract ;  the  occipital  lobe  is  the  cortical  centre  for  the 
sense  of  sight.  As  there  is  only  a  partial  crossing  of  the 
fibres  in  the  chiasma  of  the  optic  nerve,  an  injury  to  the 
occipital  lobe  or  to  the  optic  tract  as  far  as  the  chiasma 
may  cause  hemianopsia,  /.  ^.,  blinding  on  the  correspond- 
ing side  of  the  retina  ;  thus  a  diseased  condition  of  the 
right  side  causes  a  blindness  in  the  left  half  of  the  field 
of  vision.  A  diseased  condition  of  the  central  part  of 
the  chiasma  causes  a  bitemporal  hemianopsia.  In  an 
injury  to   the    optic    nerve   beyond    the    chiasma,  there 


THE  NERVOUS   SYSTEM.  12$ 

occurs  amblyopia,  or  amaurosis  of  one  entire  eye.  The 
temporal  lobes  are  connected  with  the  sense  of  hearing. 
The  functions  of  the  corpus  striatum,  nucleus  lenti- 
formus,  and  thalamus  opticus  are  not  exactly  known,  but 
as  they  border  on  the  inner  capsules,  diseased  conditions 
of  them  may  indirectly  cause  hemiplegia.  The  cerebel- 
lum is  said  to  be  the  centre  for  coordination.  When  it  is 
diseased,  we  have  ataxia,  dizziness,  and  vomiting. 

The  motor  fibres  of  the  psychomotor  cortical  portion 
pass  through  the  peduncle  of  the  corpus  callosum,  and 
converge  to  the  inner  capsule,  where  they  run  in  the 
middle  third  of  the  posterior  crus  between  the  opticus 
thalamus  and  the  nucleus  lentiformis.  In  its  posterior 
third  the  sensory  tracts 

^  Anterior  pyramidal  tract. 

are   found.     From    the  ^"^^„V°'      ^^  W^       *.     ,.    , 

root.  /^\r%^7/^\    ^^  Antero-lateral 

inner  capsule  the  motor  /    JIKnk  '\     "^"' 

/  ^  V_,  Lateral   pyramidal 

tracts  pass  through  the  mT,  '^^  ^''^^^• 

.      .  ^^&l|if  /l|-Tr  Nji^^fe^:-—  Cerebellar  lateral 

pes  cruris  cerebri   (the  ^m^^^m'      ^''^^^■ 

Posterior /~~^'^\^~"\      "^ — Tract  of  Burdach. 

sensory  through  the  teg-    -ot.  ^ractofLi. 

mentum  cruris  cerebri) 

into  the  pons.  The  motor  fibres,  after  their  exit  from  the 
pons  into  the  medulla,  form  the  pyramidal  bodies,  and 
here,  for  the  most  part,  cross.  The  crossed  fibres  in  the 
lateral  tract  of  the  spinal  cord  pass  downwards  (lateral 
pyramidal  tract.  Fig,  60)  ;  only  a  small  part  of  the  motor 
fibres  remains  uncrossed,  and  passes  down  in  the  middle 
part  of  the  anterior  tract  (anterior  pyramidal  tract).  A 
destruction  of  any  part  of  this  motor  tract  produces,  not 
only  a  paralysis  of  the  muscle  concerned,  but  also  de- 
scending degeneration  of  the  pyramidal  tracts,  inasmuch 
as  their  trophic  centre  is  situated  in  the  cerebrum. 
The  motor  fibres  pass  out  of  the  pyramidal  tracts  into  the 
anterior  cornu  of  the  gray  matter,  whose  great  ganglion 


126  CLINICAL   DIAGNOSIS. 

cells  form  the  trophic  centre  for  the  peripheral  motor 
nerves  and  the  muscles  ;  and  from  there  they  pass  through 
the  anterior  roots  to  the  periphery  of  the  body. 

Injuries  of  the  motor  nerves  beyond  the  gray  anterior 
cornua,  or  a  morbid  condition  of  them,  produce  a  degen- 
eration of  the  nerves,  as  well  as  paralysis  and  atrophy  of 
the  muscles,  with  the  reaction  of  degeneration.  These 
paralyses  are  characterized  as  peripheral^  in  distinction 
from  central  paralyses^  which  are  caused  by  a  lesion  of  the 
motor  tracts  proximal  to  the  gray  anterior  cornua. 

Inasmuch  as  in  the  cerebral  cortex  the  motor  centres 
of  the  single  muscular  regions  lie  far  apart  from  each 
other,  a  lesion  in  that  particular  place  generally  produces 
monoplegia,  i.  e.,  a  paralysis  of  one  member  or  of  one 
group  of  muscles  alone,  which  is  often  connected  with 
paroxysmal  cramps  in  the  paralyzed  portion  (cortical 
epilepsy,  Jackson's  epilepsy).  Lesion  of  the  inner  cap- 
sule generally  produces  total  hemiplegia,  as  well  as  affec- 
tions of  the  crus  cerebri  and  the  pons.  (In  case  of  dis- 
eased condition  of  the  crus  cerebri,  there  is  often  with  it 
a  crossed  paralysis  of  the  oculomotorius  ;  when  the  pons 
is  diseased,  there  is  crossed  paralysis  of  the  facialis.)  All 
these  paralyses  affect  the  opposite  side  of  the  body,  while 
affections  of  the  spinal  cord  before  the  pyramidal  decus- 
sation cause  paralyses  of  the  same  side.  As  most  lesions, 
however,  affect  the  spinal  cord  on  both  sides  alike,  para- 
plegia is  the  principal  form  of  spinal  paralysis  (myelitis, 
compression  of  the  spinal  cord  by  spondylitis  or  tumors). 
Injuries  of  the  anterior  roots,  of  the  plexus,  and  of  the 
nerves,  produce  paralyses  of  single  groups  of  muscles. 

The  sensory  nerves,  whose  trophic  centre  is  situated  in 
the  intervertebral  ganglia,  enter  the  spinal  cord  through 
the    posterior   roots,  cross    shortly  after  their  entrance 


THE  NERVOUS  SYSTEM.  12/ 

(deep  decussation),  and  ascend  through  the  posterior 
columns  to  the  brain,  so  that  the  inner  columns  (of  Goll) 
contain  the  long,  ascending  bundles  of  fibres,  while  the 
outer  columns  (of  Burdach)  are  made  up  of  short  bundles 
which  run  to  the  gray  posterior  cornua.  Besides  that, 
long  bundles  in  the  lateral  column  of  the  cerebellum 
pass  upward. 

In  cases  of  transverse  section  of  the  spinal  cord,  the 
columns  of  Goll  and  cerebellar  lateral  columns  degenerate 
upward  from  the  point  of  injury,  and  the  pyramidal  column 
downw^ard.  In  case  of  a  lesion  of  one  side  of  the  spinal 
cord,  there  appears  a  motor  paralysis  of  the  same  side,  and 
anaesthesia  of  the  other  side  ;  besides  this,  a  narrow  anaes- 
thetic belt  around  the  body  at  the  height  of  the  lesion 
(Brown-Sequard).  In  case  of  tabes  dorsalis  the  posterior 
columns  are  diseased,  and  in  spastic  paralyses  the  lateral 
columns  (tabes  spastica).  In  amyotrophic  lateral  scle- 
rosis the  anterior  cornua  and  lateral  columns  are  dis- 
eased, and  in  infantile  paralysis  and  progressive  muscular 
atrophy  the  gray  anterior  cornua  are  diseased.  In  dis- 
eases of  the  gray  nuclei  of  the  medulla  oblongata  (bulbar 
paralysis)  there  are  disturbances  of  speech  and  degluti- 
tion caused  by  paralysis  and  atrophy  of  the  lips,  soft 
palate,  muscles  of  deglutition,  and  larynx. 

Cranial    Nerves. 

1.  Olfactorius.  The  testing  of  the  sense  of  smell  is  accomplished 
by  holding  before  the  nose  odoriferous  and  irritating  substances,  such 
as  volatile  oils,  asafoetida,  musk,  etc. 

2.  Opticus.  Test  the  sharpness  and  field  of  vision,  and  sense  of 
color,  and  then  examine  with  the  ophthalmoscope. 

3.  Oculomotoritis  supplies  the  levator  palpebrae  superioris,  rectus 
superior,  internus,  and  inferior,  obliquus  inferior,  and  sphinctor  pu- 
pjllse.  In  paralysis,  there  is  ptosis,  diplopia,  dilatation,  and  absence 
of  pupillary  reaction,  and  disturbance  of  accommodation, 


128  CLINICAL    DIAGNOSIS. 

4.  Trochlearis  supplies  the  obliquus  superior. 

5.  Trigemi7itis .  The  motor  pert  supplies  the  muscles  of  mastica- 
tion, the  masseter,  temporalis,  pterygoid,  mylohyoid,  and  the  ante- 
rior belly  of  the  biventer.  The  sensor}'  part  supplies  the  skin  of  the 
face  and  head  as  far  as  the  ears.  The  first  branch  goes  to  the  skin 
of  the  forehead,  of  the  top  of  the  head,  of  the  upper  eyelids,  and  of 
the  bridge  of  the  nose.  The  second  branch  supplies  the  upper  half 
of  the  cheek  and  upper  lip,  and  the  third  branch,  the  lower  half  of 
the  cheek,  the  skin  in  the  temporal  region,  and  the  chin.  Besides 
this,  the  trigeminus  supplies  the  cornea  and  conjunctiva  and  the  mu- 
cous membrane  of  the  mouth  and  nose,  and  the  dura  mater  with  sen- 
sory fibres.  The  lingualis  from  the  trigeminus  is  the  nerve  of  taste 
for  the  anterior  two  thirds  of  the  tongue. 

6.  The  abdiicetis  supplies  the  abducens  muscle.  When  it  is  para- 
lyzed, the  eyeball  cannot  be  turned  outward. 

7.  The  facialis  supplies  all  the  mimic  muscles  of  the  face,  and  the 
stylohyoideus,  and  the  posterior  part  of  the  biventer.  From  the  re- 
lation of  the  facialis  to  the  petrosus  superficialis  major  nerve,  and  to 
the  chorda  tympani,  it  is  clear  that  in  a  lesion  of  this  nerve,  proximal 
to  the  ganglion  geniculi,  the  soft  palate  on  the  same  side  is  paralyzed 
and  hangs  lower,  and  that  in  a  lesion  between  the  ganglion  geniculi 
and  the  passage  of  the  chorda  tympani,  disturbances  of  taste  occur  in 
the  anterior  two  thirds  of  the  tongue,  with  decrease  of  the  salivary- 
secretion.  In  central  paralysis  of  the  facialis,  only  the  lower  half 
of  the  face  is  usually  paralyzed  ;  in  peripheral  paralysis,  only  the 
upper  part. 

8.  Acusticus.  The  power  of  hearing  should  be  tested,  and  oto- 
scopic  examination  made. 

g.  Glossopharyngeus .  The  nen^e  of  taste  for  the  posterior  third  of 
the  tongue  supplies  the  palate  with  sensory  fibres.  The  test  is  to 
apply  quinine,  sugar,  salt,  or  vinegar  to  the  part. 

10.  The  vagus  supplies  the  larynx,  pharynx,  and  oesophagus  with 
motor  and  sensory  fibres,  and  sends  fibres  to  the  contents  of  the  chest 
and  abdomen.  Irritation  of  the  vagus  causes  slowing  of  the  pulse  ; 
and  paralysis  of  the  nerve,  a  quickening  of  the  pulse  and  slowing  of 
the  respiration. 

11.  The  accessorius  supplies  the  stern o-cleido-mastoid  and  the 
trapezius. 

J2,   The  hypGglosstis,  the  motor  nerve  of  the  tongue,   supplies  th^ 


THE  NERVOUS   SYSTEM.  I29 

genio-glossus,  hyo-glossus,  stylo-glossus,  the  innermost  muscles  of  the 
tongue,  the  genio-hyoideus,  omo-hyoideus,  sterno-hyoideus,  hyo- 
thyroideus,  and  stemo-thyroideus.  In  paralysis  of  the  hypoglossus, 
the  tongue  turns  toward  the  paralyzed  side. 

Spinal  Nerves. 

1.  Plextis  cervicalis  (ist-4th  cervdcal  nerve)  supplies  the  post-occi- 
pital region  behind  the  ear,  neck,  and  shoulders  with  sensorv'  nerves  ; 
the  deep  cervical  muscles  and  the  scaleni,  with  motor  nerves.  From 
the  fourth  cer\'ical  ner\'e  the  phrenic  branches,  and  forms  the 
motor  nerve  of  the  diaphragm. 

2.  Plexus  brachialis  (5th-Sth  cervical  nerve,  ist  and  2d  dorsal 
nerve).  In  lesion  of  a  certain  pail  of  this  plexus,  there  is  a  motor 
paralysis  of  the  deltoid,  biceps,  brachialis  internus  [anticus],  supin- 
ator longus,  infraspinatus  (paralysis  of  Erb). 

The  nervi  thoracici  anterioj'es  supply  the  musculus  pectoralis  major 
and  minor. 

The  nervtis  iJioracicns  longus  supplies  the  musculus  serratus  anticus 
major  [serratus  magnus]. 

The  nervus  dorsalis  scapuhe  supplies  the  musculi  rhomboidei,  levator 
[anguli]  scapulae,  and  serratus  posticus  superior. 

The  nervus  siiprascapularis  supplies  the  musculus  supraspinatus 
and  infraspinatus. 

The  nervus  subscapularis  supplies  the  musculus  subscapularis,  teres 
major,  and  latissimus  dorsi. 

The  nervus  axz7/ar/j- supplies  the  musculus  deltoideus,  teres  minor, 
and  sensory  fibres  go  to  the  skin  of  the  outer  side  of  the  upper  arm. 

The  nervus  cutaneus  mediiis  and  medialis  supply  the  skin  of  the 
median  (inner  surface)  side  of  the  forearm. 

The  7iervus  niusctilocutaneus  supplies  the  musculus  biceps,  coraco- 
brachialis,  brachialis  internus  [anticus],  and  the  skin  on  the  radial 
side  of  the  forearm. 

The  nervus  inedianus  supplies  the  musculus  flexor  carpi  radialis, 
pronator  [radii]  teres  and  pronator  quadratus,  flexor  digitorum  com- 
munis superficialis  and  profundus  (in  part),  palmaris  longus,  flexor  pol- 
licis  longus  and  brevis,  abductor  and  opponens  pollicis  ;  the  skin  of 
the  palmar  surface  of  the  hand  from  the  thumb  to  the  middle  of  the 
third  [ring]  finger  ;  and  the  dorsal  side  of  the  ungual  phalanx  of  the 
first  and  second  finger. 


130  CLINICAL   DIAGNOSIS. 

In  paralysis  of  this  nerve,  pronation  and  flexion  of  the  hand  is  al- 
most entirely  impossible,  and  flexion  and  opposition  of  the  thumb 
and  flexion  of  the  finger  in  the  last  two  phalanges,  is  impossible  ;  on 
the  contrary,  the  first  phalanges  can  be  flexed  by  the  interossei. 
With  the  last  three  fingers,  whose  flexor  profundus  is  partly  supplied 
by  the  nervus  ulnaris,  the  power  of  grasping  is  still  retained. 

The  neriJits  ulnaris  supplies  the  musculus  flexor  carpi  ulnaris,  flexor 
digiiorum  profundus  for  the  last  three  fingers,  the  muscles  of  the  ul- 
nar side  of  the  hand,  the  interossei,  lumbricales,  adductor  pollicis  ; 
the  skin  of  the  ulnar  side  of  the  hand  on  the  palmar  side  as  far  as  the 
middle  of  the  third  [ring]  finger,  and  on  the  dorsal  side  to  the  middle 
of  ihe  second  finger. 

In  paralysis  of  this  nerve  there  is  diminished  power  of  lateral  move- 
ment towards  ihe  ulnar  side  as  well  as  loss  of  power  to  flex  the  last 
three  fingers  :  further,  also,  there  is  loss  of  motion  of  the  little  fin- 
ger in  flexion  of  the  first  phalanges  and  extension  of  the  last  pha- 
langes of  the  four  last  fingers,  and  loss  of  power  to  spread  the  fingers 
out  and  draw  them  together.  In  paralyses  Avhichhave  existed  a  long 
time  we  have  the  claw-like  position  of  the  hand,  in  which  case  the 
first  phalanges  are  flexed  towards  the  dorsal  surface  and  the  end 
phalanges  towards  the  palmar  surface.  This  is  caused  by  atrophy  of 
the  interossei. 

The  nervtis  radialis  supplies  the  extensors  of  the  arm,  hand,  and 
fingers,  the  musculus  triceps,  supinator  longus  and  brevis,  all  the 
muscles  on  the  posterior  surface  of  the  forearm,  namely,  the  extensor 
carpi  radialis  longus  and  brevis,  extensor  carpi  ulnaris,  extensor  digi- 
torum  communis,  extensor  indicis  and  digiti  minimi,  extensor  pol- 
licis longus  and  brevis,  abductor  pollicis  longus.  The  cutaneous 
branches  go  to  the  posterior  surface  of  the  upper  arm  and  forearm,  to 
the  dorsal  surface  of  the  thumb,  and  the  skin  as  far  as  the  middle  of 
the  second  finger. 

In  paralysis  of  this  nerve  there  is  inability  to  extend  the  relaxed 
muscles  of  the  hand  and  fingers,  as  well  as  to  extend  and  abduct  the 
thumb.  The  outstretched  arm  cannot  be  supinated  (but  on  flexion  of 
the  arm  the  forearm  can  be  supinated  by  the  biceps).  Such  a  paraly- 
sis is  observed  in  lead  paralysis,  except  that  the  supinator  longus  is 
generally  exempt.  The  sensory  disturbances  in  paralysis  of  the 
nerves  of  the  arm  may  be  inferred  from  the  above  description  of  the 
distribution  of  the  sensory  branches,  but  the  symptoms  are  generally 
less  distinctly  marked. 


THE  NERVOUS   SYSTEM.  I3I 

3.  The  dorsal  nerves  supply  the  skin  and  muscles  of  the  thorax  and 
abdomen. 

4.  The  plexus  lumbalis  (12th  cervical  to  ist-4th  dorsal  nerve)  goes 
to  the  skin  of  the  lower  abdominal  region,  of  the  anterior  surface  of  the 
thigh,  and  of  the  inner  surface  of  the  leg.  The  motor  branches  sup- 
ply the  internal  pelvic  muscles.  The  nervus  cruralis  supplies  the 
musculus  quadriceps  femoris,  sartorius,  pectineus  ;  the  nervus  obtur- 
atorius  supplies  the  musculus  obturator,  adductor  magnus,  longus, 
and  brevis,  and  gracilis. 

5.  The plextis  sacralis  (5th  lumbar  to  lst-5th  sacral  nerve)  supplies 
the  bladder,  rectum,  sexual  organs,  perineum,  and  nates  with  motor 
and  sensory  branches. 

The  ner\Tis  ischiadicus  [sciatic  nerve],  which  supplies  the  skin  on 
the  posterior  surface  of  the  thigh,  on  the  outer  side  of  the  leg,  and  on 
the  foot  as  well  as  the  musculus  biceps,  semitendinosus  and  semi- 
membranosus, divides  half  way  down  the  thigh  into  the  nervus  tibialis 
and  peroneus,  the  former  of  which  supplies  the  muscles  on  the  pos- 
terior surface  of  the  leg  (calf  muscles)  and  of  the  under  surface  of  the 
foot,  the  latter  going  to  the  muscles  on  the  anterior  surface  of  the  leg 
and  foot  (see  Figs.  58  and  59). 


CHAPTER  XIII. 

ANALYSIS  OF  THE  PATHOLOGICAL  CON- 
CREMENTS. 

Urinary  Concrements. — The  concrement  should 
be  rubbed  to  a  fine  powder,  and  a  part  of  it  heated  red 
hot  on  a  platinum  spatula  or  on  a  porcelain  crucible 
top.  If  the  concrement  be  completely  destroyed,  or  if 
only  a  small  amount  of  ash  remain  behind,  then  it  con- 
sists of  organic  substance,  /.  <?.,  uric  acid,  urate  of  am- 
monia, xanthin,  or  cystin. 

Uric  Acid  is  tested  for  with  the  murexide  test,  by  moist- 
ening some  of  the  powder  on  a  crucible  lid  with  a  drop 
of  nitric  acid  and  slowly  evaporating  it.  If  uric  acid  is 
present  an  orange-red  mark  is  left,  which  turns  purple  on 
being  moistened  with  ammonia.  Uric  acid  calculi  are 
generally  reddish-yellow  and  hard. 

Ammonia  is  tested  for  by  dissolving  the  powder  with 
dilute  hydrochloric  acid,  filtering  and  making  the  filtrate 
alkaline  with  caustic  potash,  and  heating  it  in  a  test  tube. 
A  smell  of  ammonia  is  developed,  and  moist  red  litmus 
paper,  held  over  the  opening  of  the  tube,  turns  blue  from 
the  vapor  ;  and  a  glass  rod  moistened  with  muriatic  acid 
and  held  over  the  opening  of  the  tube  causes  a  vapor  of 
chloride  of  ammonia.  If  uric  acid  and  ammonia  are  de- 
tected the  calculus  contains  urate  of  ammonia.  Such 
stones  are  generally  white  and  crumbly. 

If  the  murexide  test  does  not  succeed,  the  xanthin  is 

132 


PATHOLOGICAL    CÖNCREMENTS.  133 

tested  for  by  dissolving  the  powder  in  dilute  nitric  acid, 
and  evaporating  it  slowly  on  a  porcelain  crucible  top. 
If  a  lemon-colored  residue  is  left  which  is  unchanged  on 
moistening  it  with  ammonia,  but  turns  red  on  adding 
caustic  potash,  then  what  remains  is  xanthin.  Xanthin 
calculi  are  generally  of  a  cinnamon-brown  color,  moder- 
ately hard,  and  take  on  a  waxy  lustre  on  being  rubbed. 

Cystin  is  detected  by  dissolving  the  sediment  with 
heat  and  ammonia.  After  evaporating,  the  filtrate  may 
be  recognized  microscopically  as  regular  hexagonal 
crystals  of  cystin.  Cystin  calculi  are  generally  smooth, 
yellow,  and  not  very  hard. 

If  the  concrement  is  not  completely  consumed,  but 
made  black  only,  then  it  consists  of  inorganic  substances, 
or  of  compounds  of  organic  acids  (uric  or  oxalic  acid), 
with  alkalies  or  alkaline  earths. 

A  little  of  the  sediment  is  put  into  a  test  tube,  and 
dilute  hydrochloric  acid  is  added.  If  effervescence  take 
place,  it  is  proof  of  the  presence  of  carbonic  acid.  If 
the  substance  be  not  completely  dissolved  on  heating, 
then  the  residue  may  consist  of  uric  acid  (to  be  detected 
by  the  murexide  test).  It  should  then  be  filtered,  the  fil- 
trate made  alkaline  with  ammonia,  and  then  made 
slightly  acid  with  acetic  acid.  If  then  a  white  powdery 
precipitate,  insoluble  with  heat,  be  left,  it  consists  of  the 
oxalate  of  Iwie.  It  should  then  be  filtered,  and  oxalate  of 
ammonia  added.  A  white  precipitate  shows  the  pres- 
ence of  calcium  monoxide.  This  is  heated  and  filtered, 
and  ammonia  added,  and  if  a  precipitate  (ammonio- 
phosphate  of  magnesia)  be  formed  after  standing,  it 
shows  the  presence  of  viagiiesia  2c^d.  phosphoric  acid.  If 
no  precipitate  be  formed,  the  fluid  is  divided  into  two 
parts,  and  to  one  part  phosphate  of  sodium  and   to  the 


134  CLINICAL   DIAGNOSIS. 

other  sulphate  of  magnesium  is  added.  The  appearance 
of  a  precipitate  in  the  first  shows  the  presence  oimag7iesia; 
in  the  second,  of  phosphoric  acid.  Phosphoric  acid  may 
be  detected  in  the  fluid  by  adding  acetate  of  uran  after 
the  acetic  acid,  and  a  yellow-white  precipitate  shows  the 
presence  of  the  phosphate  of  uran. 

Sulphuric  acid  m.dij  be  detected  by  adding  chloride  of 
barium  after  the  muriatic  acid,  and  a  white  precipitate  of 
the  sulphide  of  barium  results  if  sulphuric  acid  be 
present. 

Calculi  of  the  oxalate  of  lime  are  generally  very  hard, 
of  a  mulberry  shape,  and  are  colored  dark  with  the  col- 
oring matter  of  the  blood.  They  are  not  dissolved  by 
acetic  acid  ;  but  are  dissolved  without  effervescence  by 
the  mineral  acids. 

Calculi  of  the  phosphate  of  lime  and  of  ammonio- 
phosphate  of  magnesia  are  generally  white,  soft,  and 
friable. 

Calculi  of  the  carbonate  of  lime  are  white,  chalky,  and 
effervesce  on  adding  acids. 

The  concrements  of  the  intestine  (fsecal  calculi) 
consist  partly  of  organic  substances  of  different  kinds, 
and  partly  of  inorganic  salts,  such  as  the  phosphate  of 
calcium,  the  ammonio-phosphate  of  magnesia,  the  sul- 
phates of  the  mineral  alkalies.  They  should  be  dissolved 
in  muriatic  acid,  and  examined  in  the  customary  manner. 

Salivary  calculi  generally  consist  of  carbonate  of 
lime. 

Gall  stones  consist  principally  of  Cholesterine  and 
bilirubin,  in  combination  with  calcium.  To  detect 
Cholesterine  the  powdered  concrement  should  be  dis- 
solved in  hot  alcohol,  and  filtered,  and  after  cooling  the 
Cholesterine    crystallizes  out  of    the    filtrate  in    slender 


PATHOLOGICAL    CÖNCREMENTS.  135 

plates.  If  the  Cholesterine  be  then  dissolved  in  chloro- 
form and  concentrated  sulphuric  acid  be  added,  a  beau- 
tiful cherry-red  color  is  formed,  which  changes  later  to 
blue  and  green.  To  test  for  bilirubin  the  residue  of  the 
concrement  is  made  slightly  acid  with  muriatic  acid  and 
extracted  with  chloroform  in  a  warm  place.  On  adding 
fuming  nitric  acid  to  the  chloroform  the  Gmelin  reaction 
appears. 


CHAPTER  XIV. 

METABOLISM  AND  NUTRITION. 

Ix  order  that  the  human  organism  shall  retain  its 
proper  amount  of  albumen,  fat,  ashy  residue,  and  water, 
there  must  be  a  suflicient  amount  and  proper  proportion 
of  these  substances  in  the  daily  food.  Since  the  water 
and  ashy  residue  are  generally  abundant,  the  principal 
question  is  of  giving  those  nutritious  substances  which 
prevent  the  body  from  losing  albumen  and  fat.  These 
substances  are  the  albuminous  and  fatty  matters  and  the 
carbo-hydrates. 

In  order  to  see  whether  an  organism  keeps  up  the 
proper  amount  of  nourishment  or  not,  it  is  not  sufficient 
to  consider  the  weight  alone  ;  for  the  weight  can  remain 
the  same,  or  even  increase,  while  the  nourishment  de- 
creases, as  in  cases  of  hydraemia,  even  without  visible 
oedema. 

Albumen  is  also  set  free  ^  from  the  organism  in  hunger. 
In  order  that  the  body  shall  not  lose  its  proper  amount 
of  albumen,  a  certain  quantity  should  always  be  given 
with  the  food,  which  can  be  substituted  bv  no  other  food. 
The  smallest  amount  of  albumen  with  which  the  body 
can  be  kept  up  to  its  standard  is  called  the  diet  of  sus- 
tenance.   This  for  a  medium-sized  adult  is  about  85  grams 

^  In  long-continued  complete  inanition,  about  4.26  grams  [63 
grains]  of  nitrogen,  equivalent  to  210  grams  [6|  ounces]  of  muscle, 
are  split  up  and  set  free  daily. 

136 


METABOLISM  AND  NUTRITION.  1 37 

[2J  ounces]  (Voit  0.  If  more  albumen  be  given  more  is 
decomposed,  and  the  body  soon  sets  it  free  and  quickly 
regains  its  nitrogenous  equilibrium,  /.  ^.,  just  as  much  is 
excreted  as  is  taken  up.  The  body  possesses  extensive 
powers  of  adaptation  and  can  reach  the  nitrogenous  equi- 
librium with  the  most  different  amounts  of  albumen,  in 
case  it  does  not  fall  below  the  diet  of  sustenance.  Be- 
sides the  amount  of  albumen  necessary  for  the  diet,  the 
amount  of  albuminous  decomposition  is  also  dependent 
upon  the  body's  richness  in  albumen,  and  therefore  a 
muscular  working  man  needs  larger  amounts  of  nutritive 
albumen,  than  a  reduced  sick  man.  The  work  itself  has 
therefore  no  influence  upon  the  amount  of  albumen  con- 
verted ;  for  the  workman  sets  free  just  as  much  albumen 
when  resting  as  when  working.  If  less  albumen  be  given 
with  the  food  than  is  necessary  to  keep  the  normal 
amount  in  the  body,  the  organism  loses  its  albumen 
and  becomes  poorer  ia  albumen.  An  increase  of  albu- 
men in  the  body  cannot  be  brought  about  by  admin- 
istering albuminous  food  only,  but  in  addition  there 
should  be  large  quantities  of  fat  and  the  carbo-hydrates 
in  the  diet,  which  prevent  the  albumen  from  splitting  up 
and  thus  economize,  as  it  were,  the  albumen.  In  fever 
more  albumen  is  decomposed  than  normally,  and  the  body 
may  therefore  lose  an  enormous  amount  of  albumen, 
when  very  little  is  taken  in  with  the  food. 

Since  the  nitrogen  w^hich  arises  from  the  split-up  albu- 
men is  almost  exclusively  excreted  through  the  urine 
(generally  as  urea,  cf.  p.  70),  the  amount  of  albumen  con- 
verted in  the  organism  may  be  calculated  from  the  amount 
of  nitrogen  in  the  urine.     One  gram  [15  grains]  of  nitro- 

^  Other  authors  give  lower  figures  :  56  grams  [if  ounces],  Meinert  : 
57  grams  [if  ounces],  Playfair, 


138  CLINICAL   DIAGNOSIS. 

gen  in  the  urine  is  equivalent  to  a  change  of  6.25  grams 
[93  grains]  of  albumen,  or  of  29.4  grams  [449  grains]  of 
muscle  (i  gram  [15  grains]  of  urea  is  equivalent  to  2.9 
grams  [43  grains]  of  albumen  and  13.72  grams  [205 
grains]  of  muscle).  If  the  amount  of  albumen  in  the 
food  be  known  and  also  the  amount  passed  with  the  fae- 
ces, by  comparing  these  figures  with  the  nitrogen  excreted 
in  the  urine,  it  may  be  decided  whether  the  organism  has 
the  proper  amount  of  nitrogen,  or  whether  it  has  gained 
or  lost  albumen.  If,  for  example,  a  patient  with  typhoid 
fever  take  in  twenty-four  hours  5.977  grams  [90  grains] 
of  nitrogen,  of  which  1.087  grams  [16  grains]  of  nitrogen 
are  passed  out  with  the  fsces  and  19,488  grams  [292 
grains]  with  the  urine,  the  body  loses  in  this  time  14.598 
grams  [218  grains]  more  than  it  has  assimilated,  /.  <?.,  it  has 
lost  91.236  grams  [1368.  grains]  of  albumen  (14.598  X  6.25 
grams  [218  X  93  grains])  or  429.2  grams  [6478.  grains] 
of  muscle  (14.59S  X  29.4  grams  [218  X  441  grains]). 

A  comparison  of  the  amount  of  urea  in  disease  with 
that  in  healthy  individuals  who  are  under  entirely  differ- 
ent conditions  of  nourishment,  is  not  possible  according 
to  the  above. 

In  diseases  of  the  urine-producing  organs,  as  in  nephri- 
tis, all  the  products  formed  in  the  body  from  the  splitting 
up  of  albumen  are  not  always  excreted  by  the  kidney,  but 
they  may  be  retained  in  the  body.  The  danger  of  poi- 
soning with  these  matters  (uraemia)  is  greater,  as  is  easily 
understood,  the  more  albumen  taken  in  as  food,  and  con- 
sequently with  it  the  formation  of  products  of  albumi- 
nous decomposition. 

The  change  of  the  noji-nitrogenous  substances,  /.  ^.,  of 
the  fats  and  carbo-hydrates,  is,  as  opposed  to  that  of  the 
albuminous  formations,  dependent   upon   the  ainotmt  of 


METABOLISM  AND   NUTRITION.  1 39 

work  and  the  p7'oduction  of  heat.  For  example,  a  laborer, 
when  working,  sets  free  twice  as  much  as  when  he  is  rest- 
ing. In  fever  when  there  is  an  increased  production  of 
heat,  there  is  also  an  increased  metabolism  of  the  non- 
nitrogenous  substances.  The  products  of  the  metabolism 
of  these  substances  are  oxidized  to  water  and  carbonic 
acid  and  leave  the  body  through  the  lungs.  If  less  non- 
nitrogenous  food  is  taken  in  than  the  body  needs  for 
work  and  the  production  of  heat,  then  a  part  of  the  fat  of 
the  body  is  used.  And  if  more  fat  or  carbo-hydrates  be 
taken  up  than  are  used,  then  fat  is  deposited.  The  fats 
and  carbo-hydrates  are  the  principal  non-nitrogenous 
substances  which  are  taken  in  as  food,  and  they  may  take 
each  other's  place  as  food,  just  in  proportion  to  the  amount 
of  heat  (calories)  which  they  contribute  to  combustion. 
When  a  certain  quantity  of  albuminous  substances  (suste- 
nance) is  given,  never  mind  what  substances  they  are;  loo 
grams  [1500.  grains]  of  fat  have  the  same  value  (isodyna- 
mic)  as  211  grams  [3155.  grains]  of  albumen,  or  232 
grams  [3480.  grains]  of  starch,  or  234  grams  [3510  grains] 
of  cane  sugar,  or  256  grams  [3840  grains]  of  grape  sugar 
(Rubner). 

If  the  object  be  to  increase  the  amount  of  fat  in  an 
individual,  then  a  smaller  amount  of  albuminous  sub- 
stances, with  a  very  abundant  non-nitrogenous  diet  should 
be  given,  and  since  fat  cannot  easily  be  taken  in  larger 
amounts  than  of  100  grams  [1500.  grains],  the  carbo- 
hydrates should  be  used.  On  the  contrary,  if  the  wish 
be  to  decrease  the  amount  of  fat  in  a  body,  then  the 
smallest  possible  quantities  of  fat  and  carbo-hydrates 
with  plenty  of  albuminous  food  should  be  given,  and 
care  should  be  taken  that  the  fat  be  burned  up  by  suffi- 
cient exercise  (work).      In  diabetes  the   organism  has 


I40 


CLINICAL   DIAGNOSIS, 


lost  in  a  varying  degree  the  ability  to  split  up  and  use 
the  carbo-hydrates.  They  are  excreted  in  the  urine 
unused  as  grape  sugar.  On  the  contrary,  the  body  splits 
up  large  quantities  of  albumen  and  fat,  and  the  loss  of  the 
carbo-hydrates  therefore  must  be  made  up  by  a  diet  very 
rich  in  albumen  and  fat,  but  poor  in  the  carbo-hydrates. 

The  need  of  these  substances  is,  therefore,  very  differ- 
ent for  different  persons.  According  to  C.  v.  Voit  the 
amount  of  food  necessary  for 


Albumen 

Fat 

Carbo- 

N. 

C. 

(grams). 

(grams). 

hydrates 
(grams). 

(grams). 

(grams). 

A    muscular    work- 

118 

56 

500 

19 

328 

man  (of   70  kilo  ' 

[3f  OZ.] 

[if  OZ.] 

[I5i  OZ.] 

Boz.] 

[10  OZ.] 

[140  lbs.]  ) 

A  moderately  strong 

127 

89 

362 

man  (physician) 

[4  OZ.  j 

[2f  OZ.] 

[11  OZ.] 

An  idle  man  (priso- 

87 

22 

305 

ner) 

[2|  OZ.] 

[f  OZ.] 

[9  OZ.] 

The  need  of  food  for  growing  individuals  (children) 
is  less  than  for  adults,  but  greater  in  proportion  to  the 
weight  of  the  body. 

The  composition  of  the  most  important  kinds  of  food 
is  given  in  the  table  opposite. 

The  nutritive  substances  are  not  completely  absorbed 
in  the  intestinal  canal,  but  a  part  of  them  is  always 
passed  out  unused  with  the  faeces.  Under  normal  con- 
ditions animal  albumen  (meat,  eggs,  cheese,  etc.)  is  very 
thoroughly  used  up,  while  vegetable  albumen  (bread, 
legumes,  vegetables)  are  less  thoroughly  absorbed.     The 

^  According  to  Pflüger  and  Bohland  the  amount  of  albumen  con- 
verted is  in  adults  (of  62  kilo  [124  lbs.]  )  equivalent  to  96.467  grams 
[1447-  grains]. 


METABOLISM  AND  NUTRITION, 

Composition  of  Foods. 


141 


-fc^ 

"SÄ 

^ 

5 

'^ 

0  't 

Food 

£ 

N.^ 

Ca    ^ 

C/5 

Xi 

\m 

^U 

;3 

in 

< 

A 

Raw  beef,    lean,  freed  from  all 

visible  fat        .... 

24.1 

18.36 

3.4 

0.9 

] 

Raw  beef,  moderately  fat  . 

27-75 

20.91 

5.19 

0.48 

•2 

Raw  beef,  fat     . 

44-58 

17.19 

26.38 

•i 

Boiled  beef         .... 

24.2 

21.8 

0.9 

3 

Roast  beef          .... 

41.43 

4.89 

6.78 

4 

Raw  veal    ..... 

27.69 

18.88 

7-41 

0.07 

•I 

Roast  veal           .... 

21. 0 

15-3 

5.2 

A 

Raw  chicken  (lean) 

23.78 

19.72 

1.4 

1.27 

•> 

Hens'  eggs  (after  taking  off  the 

shell) 

26.1 

14.1 

2. 19 

10.9 

1 

I  egg  weighs,  without  the  shell, 

on  an  average,  45  grams  [i| 

ounce]. 

Cow's  milk  (good  quality)  . 

12.92 

4.13 

0.64 

3.90 

4.20 

1 

Cow's  milk  (inferior  quality) 

II. 7 

3-5 

0.5 

2.7 

4-5 

5 

Butter 

88.3 

0.5 

87.0 

0.5 

■J 

Cheese 

66.8 

32.2 

4-75 

26.6 

2.97-' 

A 

Bacon          ..... 

95-6 

b 

Wheat  flour  (fine) 

85.14 

8.91 

1.42^ 

I. II 

74.28 

-' 

White  bread       .... 

72.0 

9.6 

1.5' 

1.0 

60.0 

3 

Black  bread        .... 

63.29 

8.5 

I.O 

52.5 

1 

Pastry  food  (the  average  of  seven 

varieties)          .... 

44.2 

8.7 

15.0 

28.9 

3 

Raw  potatoes  (without  skin) 

26.62 

2.31 

0.37 

23-3 

4 

Cooked  potatoes  (without  skin)  . 

25-4 

2.18 

0.35 

23.0 

4 

Uncooked  peas  .... 

86.59 

21.25 

3-40 

1. 17 

61.8 

4 

Rice 

86.5 

8.31 

1.33 

89.2 

4 

Vegetables  (average)  . 

27-7 

2.2 

0.35 

3-9 

18. 1 

6 

Bouillon     ..... 

0.09 

0.057^ 

0.8 

■^ 

Soup  (the  average  of  ten  varieties) 

8.4 

I.I 

1-5 

5-7 

2 

White  wine         .... 

14.0 

0.033 

2.0 

Red  wine  (French) 

II. 7 

0.0182^ 

2.34 

Sherry         ..... 

20.5 

0.20 

3-27 

•-' 

Bavarian  beer    .... 

9-7 

0.44 

5-78 

^  Analysis  of  C.  v.  Voit  ;    -  of  König  ;    ^  of  Renk  ;    ^  of  Rubner 
5  of  F.  Midler  ;  ^  of  Hoffmann. 


142 


CLINICAL  DIAGNOSIS. 


carbo-hydrates  (starch,  sugar)  are  generally  very  com- 
pletely used  up,  while  a  very  large  part  of  the  fats  is 
passed  out  unused  with  the  fasces.  In  many  pathological 
conditions  the  absorption  of  the  nutritious  substances  is 
badly  carried  out,  as  in  diarrhoea.  In  absence  of  gall  in 
the  intestine  (icterus),  the  fats  are  not  easily  absorbed. 

The  absorption  ir.  health  of  some  of  the  most  im- 
portant articles  c:  :::d  is  shown  in  the  following  table 
(Rubner)  : 


Food- 


-  ;^  »  C  ^   Ol 


X.)l  Fat  (^. 


Carbo- 
hydrates 


Fat 
of 


(lOO  grams  [3  otmcesl 
bacon) 


9.1 
4-4 
150 
4-9 
4-1 

9-4 
14.9 
11.8 

8.5 


2   •"  ; 

19.2 

9    - 

50 

S.9 

Z  •  1 

20.7 

32.0 

j 

20.5 

20.4 

32.2 

18.5 

6.1      j 

22-6 

12. 1 

17.4 

o 
I.I 

10.9 
1.6 
0.9 
7-6 

15-4 
5.3 

1.6 


Finally,  may  be  added  a  list  of  important  factors  neces- 
:a.ry  for  calculation  in  the  experiment  of  metabolism  : 
Nitrogen  :  Urea.  =  i  .  2.143. 

Nitrore-  :   A^^--.:tr.  =  i  ;  ^..i^. 

N::r:rer.  :    Vji-r::^.iz  r:.:  ^:3.::^ce  =  i  ;  29.4. 

Urea  :  Alburr.er:  ■=.  i  :  2.9. 
Urea:  Muscular  substance  =  i  ;  13.71. 
Muscular  substance  :  Nitroier.  =  i  :  c.034. 
Albumen  :  Nitrogen  =  i  :  c.i6. 


Table  of  the  Weights  of  the  Human  Body 

MALE. 


Age, 


'Height  in  ft.  and  inches. 


Weisht. 


At  birth. 
I  year. 

2 

3 
4 
5 
6 

7 
8 

9 

lO 
12 

14 

i6 
i8 

20 

25 
30 
40 
50 
60 


ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 
ft. 


7  m. 
3  in. 

8  in. 

9  in. 

3  in. 

5  in. 

8  in. 

9  in. 

2  in. 

6  in. 
10  in. 

3  in. 
6  in. 

8  in. 

9  in. 
9  in. 
8  in. 
6  in. 
5  in. 


0.496  m. 
0.696  m. 
o.  797  m. 
0.860  m. 
0.932  m. 
0.990  m. 
1.046  m. 
1. 112  m. 
1. 170  ra. 
1.227  m. 
1.282  m. 
'1.359  m. 
1.4S7  m. 
1. 610  m. 
1.700  m. 
"1.711  m. 
1.722  m. 
1.722  m. 
1. 713  m. 
1.674  ni. 
^1.664  m. 


7  lbs. 

;  3-20  kg.] 

22    " 

10.00  ' 

26    " 

12.00  ' 

29    " 

13.21  ' 

33    " 

15-07  * 

36    " 

16.70  ' 

39    " 

18.04  ' 

44    " 

20.16  ' 

49    " 

22.26  ' 

53    " 

[24.09  * 

57    " 

26.12  ' 

68    " 

31.00  ' 

89    " 

.40.50  ' 

117    " 

53-39   ' 

135    " 

61.26    ' 

143    " 

L65.00   ' 

150    " 

68.29  ' 

152    " 

68.90   ' 

151     " 

[68.81    ' 

148    " 

"67.45    ' 

144    " 

'65-50   ' 

FEMALE. 


Age. 

Height  in  ft.  and  inches. 

Weight. 

At  birth. 

I  ft. 

6  in. 

'0.483  m." 

6  lbs. 

"  2.91  kg." 

I  year. 

2  ft. 

3  in- 

0.690  m. 

20    ' 

.  9-30  ' 

2     " 

2  ft. 

6  in. 

0.7S0  m. 

25     ' 

11.40   ' 

3     " 

2  ft. 

9  in. 

^0.850  m. 

27    ' 

12.45    ' 

4     " 

3  ft. 

0.910  m. 

31    ' 

14.18    ' 

5     " 

3  ft. 

2  in. 

0.974  m. 

34    ' 

15.50   ' 

6     " 

3  ft. 

4  m. 

1.032  m. 

37     ' 

16.74   ' 

7     " 

3  ft. 

7  m. 

1.096  m. 

40    ' 

.1S.45    ' 

8     " 

3  ft, 

9  m. 

1. 139  m. 

43    ' 

19.82   ' 

9     " 

3  it. 

II  in. 

1.200  m. 

50    ' 

22.44   ' 

10     " 

4tt. 

I  in. 

1.24S  m. 

53    ' 

24.24   ' 

12     " 

4  It. 

4  m. 

1.327  m. 

67    ' 

.30-54   ' 

14     " 

4  It. 

9  m. 

[1.447  m. 

84    ' 

[38.10   ' 

16     " 

4  ft. 

II  in. 

1.500  m. 

98    ' 

44-44   ' 

18     ■' 

5  ft. 

I  in. 

1.562  m. 

117    ' 

.53- 10   ' 

20     " 

5  ft. 

2  in. 

1.570  m. 

120    ' 

54-46    ' 

25     " 

5  ft. 

2  in. 

1.577  ni. 

121     ' 

'55-08    ' 

30     " 

5  It. 

2  in. 

,1.579  m._ 

121     ' 

^55-14    ' 

40     " 

5  tt. 

I  m. 

.1-555  ni. 

129    ' 

5S.45    ' 

60     " 

5  ft. 

1.516  m. 

125     ' 

[56.73    ' 

- 

144 


CLIN  IC  A  L  DIA  GNO  SIS. 


DOSE   TABLE. 

[The  döses  given  are  for  adults.  For  hypodermic  use 
the  dose  should  be  one  half,  and  for  use  by  the  rectum, 
twice  that  by  the  mouth.  The  dose  for  children  is  calcu- 
lated by  adding  1 2  to  the  age  of  the'  child,  and  divid- 
ing by  the  age,  thus  :   for  a  child  4  years  old  the  dose 

would  be  ^^^   =  4  or  ^  of  the  dose  for  adults.     The 

doses  are  given  in  terms,  both  of  the  Apothecaries'  and 
of  the  Decimal  metric  system. 


Dose   expressed 

in  terms  of 

Dose 

Remedies. 

apothecaries' 

expressed  in 

weights 

''         metric  terms. 

and  measures. 

Acet.  colchici    ..... 

f  3  ss  to  3  i 

2  to  4  ccm. 

"     lobelise    . 

Tq^  XV  to  Ix 

I  to  4  ccm. 

' '     opii 

■q  V  to  X 

0.30  to  0.60  ccm. 

"     sanguinar. 

TU  XV  to  XX 

I  to  2  ccm. 

"     Scillae       . 

TU  X  to  XXX 

0.60  to  2  ccm. 

Acid.  acet.  dil. 

TFl.  Ix  to  XC 

4  to  6  ccm. 

"     arsenios. 

gr-  Ä  to  3!^ 

o.ooi  to  0.005  gni- 

"     benzoic. 

gr.  V  to  XV 

0.30  to  I  gm. 

"     boracic.   . 

gr.  V  to  X 

0.30  to  0.60  gm. 

"     carbolic. 

gr.  j  to  iii 

0.05  to  0.20  gm. 

"     gallic. 

gr.  iij  to  XV 

0.20  to  I  gm. 

"     gall,  in  albuminuria 

gr.  X  to  Ix 

0.60  to  4  gm. 

"     hydrobrom.  (34  %)  . 

gr.  X  to  XV 

0.60  to  T  gm. 

"     hydrobrom.  dil. 

TTi  XV  to  xl 

I  to  4  ccm. 

"     hydrochlor.  dil. 

Til  X  to  XXX 

0.60  to  2  ccm. 

"     hydrocyan.  du. 

■ni  ij  to  vj 

0. 10  to  0.40  ccm. 

"     lactic. 

gr.  XV  to  Ix 

I  to  4  gm. 

"     nitr.  dil. 

Til  X  to  XXX 

0.30  to  2  ccm. 

"     nitro-hydrochlor.  dL 

.. 

Til  V  to  XX 

0.30  to  1.20  ccm. 

"     phosphoric.  (50  ^ 

gr.  iij  to  V 

0.20  to  0.30  gm. 

"     phosphoric,  dil. 

Til  X  to  Ix 

0.60  to  4  ccm 

"     saHcyl.    . 

gr.  V  to  XV 

0.30  to  I  gm. 

"     sulphuric,  dil. 

Til  V  to  XXX 

0.30  to  2  ccm. 

"     sulphuric,  atom. 

m  V  to  XXX 

0.30  to  2  ccm. 

"     sulphuros. 

TU  XXX  to  Ix 

2  to  4  ccm. 

"     tannic.     , 

gr.  ij  to  X 

o.io  to  0.60  gro. 

DOSE    TABLE. 


145 


Dose   expressed 

in  terms  of 

Dose 

Remedies. 

apothecaries' 

expressed  in 

weights 

metric  terms. 

and  measures. 

Aconitina  (white  crystals) 

gr-  ¥70  to  lio 

0.00015  to  0.0005  gm. 

Adonidine 

gr.  TO  to  \ 

0.06  to  0.02  gm. 

Aloe 

gr.  ii  to  V 

0. 10  to  0.30  gm. 

Aloe  et  canella 

gr.  V  to  xxx 

0.30  to  2.0  gm. 

Aloinum 

gr.  j  to  iij 

0.06  to  0.20  gm. 

Alumen  (expectorant 

) 

gr.  iij  to  x 

0.20  to  0.60  gm. 

"        exsiccat. 

gr.  V  to  XXX 

0.30  to  2  gm. 

Ammonii  benzoas 

gr.  X  to  XX 

0.60  to  1.2  gm. 

"         bromid. 

gr.  V  to  XXX 

0.30  to  2  gm. 

' '         carb. 

gr.  iij  to  X 

0.20  to  0.60  gm. 

"         chlorid. 

gr.  XV  to  XXX 

I  to  20  gm. 

"         iodid. 

gr.  iij  to  XV 

0.20  to  i.o  gm. 

"         phosph. 

gr.  V  to  XX 

0.30  to  1.2  gm. 

' '         picras 

gr.  i  to  ^ 

0.15  to  0.03  gm. 

"         sulph. 

gr.  iij  to  XV 

0.20  to  1.0  gm. 

' '         valer. 

gr.  iij  to  XV 

0.20  to  1.0  gm. 

Amyl  nitris 

TH,  ij  to  V 

0. 10  to  0.30  gm. 

Anthemis 

3  ss  to   3  j 

2.0  to  4.0  gm. 

Antimonii  et  pot.  tartr.  (diaph.) 

gr.  tV  to  \ 

0.004  to  o.oi  gm. 

"         et  pot.  tartr.  (emetic) 

gr.  j  to  ij 

0.05  to  0,10  gm. 

oxid. 

gr.  j  to  ij 

Q.05  to  o.io  gm. 

' '          oxysulphuret. 

gr.  \  to  11 

0.03  to  0.10  gm. 

"          sulphid.    . 

gr.  \  to  ij 

0.03  to  o.oi  gm. 

' '         sulphuret. 

gr.  i  to  11 

0.03  to  o.io  gm. 

Antipyrine 

gr.  V  to  XV 

0.30  to  1.0  gm. 

Apomorph.  hydrochlor. 

gr.  h  to  TO 

0.002  to  0.005  gm. 

Aqua  ammonige 

TT]^  VJ  to  XXX 

0.40  to  2  ccm. 

"     amygd.  amar. 

f  3  ij  to  XV 

8.0  to  16.0  ccm. 

' '     camphorae 

f  §  ss  to  ij 

15  to  60  ccm. 

"     chlori 

f  3  j  to  iv 

4  to  15  ccm. 

"     creasoti    . 

f  3  j  to  iv 

4  to  15  ccm. 

"     laurocerasi 

IHvj  to  XXX 

0.40  to  2  ccm. 

Argenti  iodidum 

gr.  i  to  ij 

0.03  to  O.IO  gm. 

"       nitras  . 

gr.  ^  to  i 

O.OI  to  0.02  gm. 

"       oxid.    . 

gr.  I-  to  ij 

0.03  to  O.IO  gm. 

Arnica 

gr.  V  to  XX 

0.30  to  1,20  gm. 

Arsenici  iodidum 

gr.  eV  to  tV 

o.ooi  to  0.005  gm. 

Asafcetida 

gr.  V  to  XX 

0.30  to  1.20  gm. 

Atropina 

gr.  T¥8  to  3V 

0.005  to  0.002  gm. 

Atropinse  sulph. 

gr.  T^8  to  ^ 

0.005  to  0.002  gm. 

146 


CLINICAL  DIAGATOSIS. 


Dose   expressed 

in  terms  of 

Dose 

Remedies. 

apothecaries' 

expressed  in 

weights 

metric  terms. 

and  measures. 

Auri  et  sodii  chlorid. 

gr.  3V  to  iV 

0.002  to  0.004  gni- 

Belladonnas  folium    . 

g^"-  J 

0.05  gm. 

Bismuthi  citras 

gr.  iij  to  XV 

0.20  to  i.o  gm. 

"         et  ammon.  citr. 

gr.  j  to  XV 

0.05  to  1.0  gm. 

"         sub-carb.    . 

gr.  vj  to  XXX 

0.40  to  2  gm. 

sub-nitr.     . 

gr.  vj  to  XXX 

0.40  to  2  gm. 

' '         tannas 

gr.  vj  to  XXX 

0.40  to  2  gm. 

"         valer. 

gr.  j  to  iij 

0.05  to  0.20  gm. 

Brucina    . 

gr.  -h  to  tV 

o.ooi  to  0.004  gm. 

Buchu 

gr.  XX  to  XXX 

1.20  to  2.0  gm. 

Caffeina    . 

gr.  j  to  V 

0.05  to  0.30  gm. 

Caffeinse  citras 

gr.  j  to  V 

0.05  to  0.30  gm. 

Calcii  bromidum 

gr,  V  to  XXX 

0.30  to  2.0  gm. 

"     carb. 

gr.  XV  to  Ix 

I  to  4  gm. 

"      hypophosphis 

gr.  iij  to  XV 

0.20  to  I  gm. 

"      iodidum 

gr.  j  to  iij 

0.05  to  0.20  gm. 

"      phosphas 

gr.  XV  to  XXX 

I  to  2  gm. 

Calumba 

gr.  X  to  XXX 

0.60  to  2.0  gm. 

Calx  sulphurata 

gl--  i  to  j 

0.02  to  0.05  gm. 

Cambogium 

gr.  I  to  iv 

0  05  to  0.25  gm. 

Camphora 

gr.  iij  to  X 

0.20  to  0.60  gm. 

Camph.  monobrom. 

gr.  ij  to  V 

o.io  to  0.30  gm. 

Cantharis 

gr.  1  to  ij 

0.03  to  0.10  gm. 

Cardamonum    . 

gr.  V  to  XXX 

0. 30  to  2  gm. 

Castoreum 

gr.  vj  to  XV 

0.40  to  I  gm. 

Catechu    . 

gr.  XV  to  XXX 

I  to  2  gm. 

Cerii  nitras 

gr.  j  to  iij 

0.05  to  0.20  gm. 

"    oxalas 

gr.  j  to  iij 

0.05  to  0.20  gm. 

Chinoidinum     . 

gr.  iij  to  XXX 

0.20  to  2  gm. 

Chloral  hydrat. 

gr.  iij  to  XV 

0.20  to  I  gm. 

Chloroformum 

TTlj  to  V 

0.05  to  0.30  ccm. 

Cinchona 

gr.  XV  to  Ix 

I  to  4  gm. 

Cinchonidina  and  its  salts 

gr.  j  to  XXX 

0.05.  to  2  gm. 

Cinchonina  and  its  salts 

gr.  j  to  XXX 

0.05  to  2  gm. 

Cinnamonum    . 

gr.  vj  to  XXX 

0.40  to  2  gm. 

Codeina    .... 

gr.  \  to  ij 

0.03  to  O.IO  gm. 

Colchici  radix  . 

gr.  ij  to  vj 

0.03  to  0.40  gm. 

"        semen 

gr.  ij  to  vj 

0.03  to  0.40  gm. 

Colocynthis 

gr.  V  to  XV 

0.30  to  1.0  gm. 

Confectio  opii  . 

gr.  X  to  XX 

0.60  to  1.20  gm. 

DOSE    TABLE. 


H7 


Dose   expressed 

Remedies. 

in  terms  of 
apothecaries' 
weights  and 

Dose  expressed  in 

metric  terms. 

measures. 

Confectio  sennse         .... 

gr.  j  to  ij 

0.5  to  o.io  gm. 

Conii  fol.           ..... 

gr.  iij 

0.20  gm. 

Coniina  and  its  salts 

gr.  -g\  to  gV 

o.ooi  to  0.002  gm. 

Copaiba    ...... 

VI  XV  to  Ix 

I  to  4  ccm. 

Creasotum         ..... 

TTi  j  to  iij 

0.05  to  0.20  ccm. 

Creta  prsepar.             .... 

gr.  XV  to  Ixxv 

I  to  5  gm. 

Croton  chloral           .... 

gr.  j  to  x 

0.05  to  0.60  gm. 

Cubeba     ...... 

gr.  XV.  to  Ix 

I  to  4  gm. 

Cupri  acetas      ..... 

gr.  1  to  vj 

0.03  to  0.40  gm. 

"      sulphas  ..... 

gr.  i  to  X 

0.03  to  0.60  gm. 

Cuprum  ammon.       .... 

gr.  i  to  j 

o.oi  to  0.05  gm. 

Curare      ...... 

gr.  T5  to  i 

0.002  to  O.OI  gm. 

Decoct,  aloes  comp. 

f  §  ss  to  ij 

15  to  60  ccm. 

"       chimaphilae 

flij 

60  ccm. 

"       citronae         .... 

f!ij 

60  ccm. 

' '       sarsap  comp. 

f  I  ij  to  vj 

50  to  200  ccm. 

Digitalinum       ..... 

gr.  eV  to  3V 

O.OOI  to  0.002  gm. 

Digitalis  ...... 

gr.  i  to  ij 

0.03  to  0.10  gm. 

Duboisina  and  its  salts 

gr.  tIj  to  ^V 

0.0005  to  O.OOI  gm. 

Elaterinum,  U.  S.  P.,  1880 

gr.  ^V  to  I'e 

O.OOI  to  0.004  g'll- 

Elaterium            "          1870 

gr.  tV  to  i 

0.004  to  0.03  gm. 

Emetina  and  salts,  (emetic) 

gr.  i  to  i 

0.008  to  0.016  gm. 

"         and  salts,  (diaph.) 

gr.  3-i^  to  3V 

0.0005  to  0.002  gm. 

Ergota      ...... 

gr.  XV  to  Ix 

I  to  4  gm. 

Ergotinum         ..... 

gr.  ij  to  viij 

0.10  to  0.50  gm. 

Eserinae  and  its  salts 

gr.  6¥  to  -^ 

O.OOI  to  0.004  gm. 

Extr.  absinthii  fl.                ... 

VI  XV  to  XXX 

I  to  2  ccm. 

'     aconiti  fol.  (Engl.)  . 

gr.  i  to  j 

0.02  to  0.05  gm. 

'     aconiti  fol.,  U.  S.  P.,  1870      . 

gr.  i  to  ij 

0.03  to  O.IO  gm. 

'     aconiti  fol.  fluid. 

-ni  i  to  V 

0.05  to  0.30  ccm. 

'     aconiti  rad.,  U.  S.  P.,   1880     . 

gr.  A  to  i 

0.005  to  0.015  gm. 

'     aconiti  rad.  fluid      .         .          . 

TTl,  ^  to  ijss 

0.03  to  0.13  ccm. 

'     agaric  fl.           .... 

TTt  V  to  XX 

0.30  to  1.20  ccm. 

'     aloes  aquos.     .... 

gr.  i  to  iij 

0.03  to  0.20  gm. 

'     anthemidis       .... 

gr.  ij  to  X 

0.10  to  0.60  gm. 

*     anthemidis  fl.            ... 

VI  XXX  to  Ix 

2  to  4  ccm. 

'     arnicse  flor.      .... 

gr.  iij  to  viij 

0.20  to  0.50  gm. 

'     arnicae  fl.          .... 

TU  V  to  XV 

0.30  to  I  ccm. 

'     arnicse  rad.       .... 

gr.  ij  to  V 

0.10  to  0.30  gm. 

'     arnicse  rad.  fl.           ... 

TTl  V  to  XV 

0.30  to  I  ccm. 

148 


CLINICAL  DIAGNOSIS. 


Remedies. 


Extr.  aiomat.  fl. 

auranlii.  cort.  fl. 
bellad.  fol.  (Engl.) 
bellad.  alcohol 
bellad.  fol.  fl. 
bellad.  rad. 
bellad.  rad,  fl, 
berber.   aquifol.  fl. 
berber.  vulg.  fl. 
brayerse  fl. 
bryoniae  fl. 
buchu  fl.  . 

calami,  fl, 
calend.  fl. 
calumbse 
calumbae  fl. 
cannab.  Amer.  fl. 
cannab.  ind.    . 
cannab.  ind.  fl. 
cantharidis  fl. 
capsici  fl. 
cardam.  comp.  fl. 
carnis 

cascarillas  fl.     . 
castanese  fl. 
catechu  liquid, 
caulophylli  fl. 
Cimicifugae  fl.  . 
cinchonae 
cinchonse  fl. 
cinchonge  arom.  fl, 
cinchonae  comp.  fl. 
colch.  rad. 
colch.  rad,  fl.   . 
colch.  sem.  fl, 
colocynth 
colocynth  comp, 
condurango  fl. 
conii  fol,   (Engl.) 
conii  fol,   ale,   U.  1 


Dose  expressed 

in  terms  of 

apothecaries' 

weights 
and  measures. 


TTL  XXX  to  Ix 
f  3  1^  to  ijss 
gr-  i  to  I 
gr.  i  to  i 
TTl  iij  to  vj 
gr-  i  to  i 
m  j  to  iij 

TT|,  XV  to  XXX 

TT!,  XV  to  XXX 
f  3  ij  to  iv 
TTj^  XV  to  Ix 
f  3  ss  to  ijss 
■n[  XV  to  Ix 
"fTj,  XV  to  Ix 
gr.  iij  to  X 

TU  XV  to  Ix 

TT[  iij  to  XV 
gr.  I  to  i 
TTi  iij  to  vj 
■ni  j  to  iij 
TTi  j  to  iij 
TTi  XV  to  xlv 
gr.  XV  to  Ix 
f  3  f  to  ijss 
f  3  I  to  ijss 
TIL  viij  to  XXX 

Til  XV  to  XXX 

TI],  viij  to  XXX 
gr.  XV  to  XXX 
TTI  XXX  to  Ix 
TT[  XXX  to  Ix 

f  3  ss  to  jss 
gr.  i_  to  li 
TTI  iij  to  XV 
TTI  1-1  to  X 

gr.  \\  to  V 
gr.  i^  to  V 
TTI  viij  to  XXX 
gr.  j  to  iv 
P.,  1870,        gr.  I  to  li 


Dose 

expressed  in 

metric  terms. 


2  to  4  ccm. 
I  to  10  ccm. 
o.oi  to  0.04  gm. 
o.oi  to  0.03  gm. 
0.20  to  0.40  ccm. 
0.008  to  0.016  gm. 
0.05  to  0.20  ccm. 
I  to  2  ccm, 
I  to  2  ccm, 
8  to  16  ccm. 

1  to  4  ccm. 

2  to  10  ccm, 
I  to  4  ccm. 

I  to  4  ccm. 
0.20  to  1.20  gm. 
I  to  4  ccm. 
0.20  to  I  ccm. 
O.OI  to  0.03  gm. 
0,20  to  0.40  ccm. 
0.05  to  0.20  ccm. 
0.05  to  0.20  ccm. 
I  to  3  ccm. 
I  to  4  gm. 

3  to  10  ccm. 
3  to  10  ccm. 
o,  50  to  2  ccm. 
I  to  2  ccm. 
0.50  to  2  ccm. 

1  to  2  gm. 

2  to  4  ccm. 
2  to  4  ccm. 
2  to  6  ccm. 
0.02  to  0.08  gm. 
0.20  to  I  ccm. 
0.08  to  1.20  ccm. 
0.08  to  0.30  gm. 
0.08  to  0.30  gm. 
0.50  to  2  ccm. 
0.05  to  0.25  gm. 
0.05  to  0.08  gm. 


DOSE    TABLE. 


149 


Dose  expressed 
in  terms  of 

Dose 

Remedies. 

apothecaries' 

weights 
and  measures. 

expressed  in 
metric  terms. 

Extr 

.  con.  (fr.)alc.,  U.  S.  P.,  1880    . 

gr.  fto  j 

0.02  to  0.05  gm. 

conii  fol.  fl.     . 

Til,  iij  to  XV 

0.20  to  I  ccm. 

con.  (fr.)  fl.  U.  S.  P.,  1880 

TU   l|  to  V 

0  03  to  0.30  ccm. 

convallariae  rad.  fl.  . 

HI,  XV  to  XXX 

I  to  2  ccm. 

cubebse  fl. 

TT|,  XV  to  XXX 

I  to  2  ccm. 

damianse  fl. 

f  3  ss  to  ijss 

2  to  10  ccm. 

delphinii  fl. 

TTL  j  to  iij 

0.05  to  0.20  ccm. 

digitalis  . 

gr.  i  to  i 

o.oi  to  0.03  gm. 

digitalis  fl. 

■ni  I  to  vj 

0.05  to  0.40  ccm. 

duboisiae 

gr.  i  to  i 

0.015  to  0.03  gm. 

duboisise  fl. 

TT[  V  to  X 

0.30  to  1.20  ccm. 

dulcamarae 

gr.  V.  to  XV 

0.30  to  I  gm. 

dulcamarse  fl. 

f  3  j  to  ij 

4  to  8  ccm. 

ergotse     . 

gr.  iss  to  viij 

0.08  to  0.5  gm. 

ergotae  fl. 

TTl,  XV  to  Ix 

I  to  4  ccm. 

erythroxyli  fl. 

f  3  ss  to  ij 

2  to  8  ccm. 

eucalypti  fl. 
euonymi  fl. 
eupatorii  fl. 
euphorb.  ipec. 
ferri.  pom. 

fl. 

TTl,  XV  to  Ix 
TTj,  XV  to  Ix 
TTl,  XXX  to  Ix 
TTj,  V  to  XXX 

gr.  iij  to  XV 

I  to  4  ccm. 

1  to  4  ccm. 

2  to  4  ccm. 
0.30  to  2  ccm. 
0.20  to  I  gm. 

frangulce  fl. 
fuci  vesiculos. 
gallse  fl. 

f  3  ss  to  ijss 

TTl,  XV  to  XXX 

f  3  ss  to  ij 

2  to  10  ccm. 

1  to  2  ccm. 

2  to  8  ccm. 

gelsemii  . 
gelsemii  fl. 

TTj,  ij  to  viij 
TTj,  j  to  viij 

o.io  to  0.50  ccm. 
0.05  to  0.50  ccm. 

gent.  fl.   .          . 
gent.  comp.  fl. 
geranii  fl. 

TTj,  XXX  to  ix 
TTl,  XXX  to  Ix 
Til  XV  too  XXX 

2  to  4  ccm. 
2  to  4  ccm. 
I  to  2  ccm. 

gossypii  fl. 

TT],  XV  to  xlv 

I  to  3  ccm. 

granali.  rad.  cort.  fl 

f  3  ss  to  ij 

2  to  8  ccm. 

grind,  rob.  fl. 

TTi  XXX  to  Ix 

2  to  4  ccm. 

guaiaci  ligni  fl. 

TIj,  XXX  to  Ix 

2  to  4  ccm. 

guaranae  fl. 

Tit  XV  to  XXX 

I  to  2  ccm. 

hgematoxyli 

gr.  V  to  XXX 

0.30  to  2  gm. 

hsematoxyli  fl. 
hamamelid  fl.  . 

TTj,  XXX  to  Ix 
TT],  XXX  to  XC 

2  to  4  ccm. 
2  to  6  ccm. 

helleb.  nigris  . 

gr.  \  to  iij 

0.03  to  0.20  gm. 

helleb  nigris  fl. 

TU,  V  to  XV 

0.30  to  I  ccm. 

humuli    . 

f 

» 

gr.  iij  to  XV 

0.20  to  I  gm, 

l^^O 


CLINICAL  DIAGNOSIS. 


Dose   expressed 

in  terms  of 

Dose 

Remedies. 

apothecaries' 

expressed  in 

weights 

metric  terms. 

and  measures. 

Extr.  humuli  fl 

TTl,  iij  to  XV 

0.20  to  1  ccm. 

'     hydrangese  fl. 

TTl,  XXX  to  Ix 

2  to  4  ccm. 

'     hydrastis 

gr.  iij  to  X 

0.20  to  1.20  gm. 

'     hydrastis  fl.     . 

ni,  V  to  xxx 

0.30  to  2.0  ccm. 

'     hyoscyami  (Engl.)    . 

gr.  j  to  iv 

0.05  to  0.25  gm. 

'     hyoscyami  ale. 

gl-.  J  to  ij 

0.05  to  0. 10  gm. 

'     hyoscyami  fol.  fl.     . 

TT]^  iij  to  XV 

0.20  to  I  ccm. 

'     hyoscyami  sem.  fl.    . 

TU  ij  to  viij 

0. 10  to  0.50  ccm. 

'     ignatiae    . 

gr.  1  to  li 

0.02  to  0.65  gm. 

'     ignatiffi  fl. 

TTl  j  to  vj 

0.05  to  0.40  ccm. 

'     ipecac  fl. 

TTi  iij  to  Ix 

0.20  to  4  ccm. 

'     iridis  versicol. 

gr.  iij  to  vj 

0.20  to  0.40  gm. 

'     iridis  versicol  fl. 

TTi  XV  too  XXX 

I  to  2  ccm. 

'     jalapas,  U.  S.  P.,  1S70 

gr.  V  tox 

0.30  to  0.60  gm. 

'     jalapae  ale. 

gr,  iij  to  vj 

0.20  to  0.40  gm. 

'     jalapse  fl. 

TTl  XV  to  Ix 

I  to  4  ccm. 

'     junip.  fl. 

TTl  xxx  to  Ix 

2  to  4  ccm. 

'     kamala  fl. 

TTl  xxx  to  Ix 

2  to  4  ccm. 

'     kino  liquid 

TTl  XV  to  xxx 

I  to  2  ccm. 

'     kramari^ 

gr.  V  to  XV 

0.30  to  I  gm. 

'     lactucae  fl. 

TTl  XV  to  Ix 

I  to  4  ccm. 

'     lactucarii  fl. 

TTl  V  to  XXX 

0.30  to  2.0  ccm. 

'     leptandrae 

gr.  iij  to  X 

0.20  to  0.60  gm. 

'     leptrandrae  fl. 

TTl  XXX  to  Ix 

2  to  4  ccm. 

'     lobelia  fl. 

TTl  j  to  V 

0.05  to  0.30  ccm. 

'     lupulini  fl. 

TTl  V  to  XV 

0.30  to  I  ccm. 

'     matico  fl. 

TTl  XXX  to  Ix 

2  to  4  ccm. 

'     myricas  fl. 

TTl  XXX  to  Ix 

2  to  4  ccm. 

'     nectandrcC  fl. 

f  3  j  to  iv 

4  to  16  ccm. 

'     nuc.  vom. 

gr.  \  to  \\ 

0,02  to  0.08  gm. 

'     nuc.  vom.  fl. 

Til  I  to  iv 

0.05  to  0.30  ccm. 

'     opii 

gr.  \  to  \ 

o.oi  to  0.03  gm. 

'     papaveris 

gr.  \  to  ij 

0.03  to  o.io  gm. 

'     papaveris  fl. 

Til  XV  to  xlv 

I  to  3  ccm. 

'     pareirce  fl. 

TTl  XXX  to  Ix 

2  to  4  ccm. 

'     petroselini  fl. 

f  3  j  to  ij 

4  to  8  ccm. 

'     physostigmce 

gr.  tV  to  \ 

0.004  to  0.01  gm. 

'     physostigmse  fl. 

TTl  j  to  iij 

0.05  to  0.20  ccm. 

'     phytolaccae  baccar.  ii. 

TTlv  to  XXX 

0.30  to  2  ccm. 

" 

*     Phytolacca  rac 

I. 

gr.  j  to  iij 

0.05  to  0.20  gm. 

DOSE    TABLE. 


151 


Dose   expressed 

in  terms  of 

Dose 

Remedies. 

apothecaries' 

expressed  in 

weights  and 

metric  terms. 

measures. 

Extr.  phytolaccse  rad.  fl.   . 

TTlV  to   XXX 

0.30  to  2  ccm. 

'     pilocarpi  fl. 

TTixV  to  Ix 

I  to  4  ccm. 

'     pimentae  fl. 

■ni,xv  to  xlv 

I  to  3  ccm. 

'     piper  nigr.  fl.  . 

TT^xv  to  xlv 

I  to  3  ccm. 

'     podophylli 

gr.  \  to  \\ 

0.03  to  0.08  gm. 

'     podophylli  fl.  . 

Tr[v  to  XXX 

0.30  to  2.0  ccm. 

'     polygoni  fl. 

TT^XV  to  XXX 

I  to  2  ccm. 

*     polygonati  fl.   . 

TTlv  to  XV 

0.30  to  I  ccm. 

'     prun.  virg.  fl.  . 

TTLxxx  to  Ix 

2  to  4  ccm. 

'     quassise    . 

gr.  j  to  V 

0.05  to  0.30  gm. 

'     quassiae  fl. 

TlXxxx  to  Ix 

2  to  4  ccm. 

'     quebracho  fl.    . 

TTix  to  Ix 

0.60  to  4  ccm. 

'     quercus  fl. 

TUxxx  to  Ix 

2  to  4  ccm. 

'     rhamni  cath.  ft.  fl. 

TT|,xxx  to  Ix 

2  to  4  ccm. 

'     rhamni  pursh.  cort.  fl. 

TTj,xxx  to  cxx 

2  to  8  ccm. 

*     rhei 

gr.  V  to  XV 

0.30  to  I  gm. 

'     rhei  fl.     . 

TTLxv  to  xlv 

I  to  3  ccm. 

'     ricini  fol.  fl.     . 

f  3  ss  to  ij 

2  to  8  ccm. 

'     rutae  fl.    . 

TTLxv  to  XXX 

I  to  2  ccm. 

'     sabinae  fl. 

TUv  to  XV 

0.30  to  I  ccm. 

'     sanguin.  fl. 

TTiv  to  XV 

0.30  to  I  ccm. 

'     santali  citr.  fl. 

f  3  j  to  ij 

4  to  8  ccm. 

'     santonicae  fl.     . 

TUxv  to  Ix 

I  to  4  ccm. 

'     sarsap.  fl. 

f  3  ss  to  ij 

2  to  8  ccm. 

'     sarsap.  comp.  fl. 

f  3  ss  to  ij 

2  to  8  ccm. 

'     sassafras  fl. 

f  3  ss  to  ij 

2  to  8  ccm. 

'     Scillae  fl.  . 

TTiv  to    XXX 

0.30  to  2  ccm. 

'     Scillae  comp.  fl. 

TTl^V  to    XXX 

0.30  to  2  ccm. 

'     scoparii  fl. 

f  3  ss  to  j 

2  to  4  ccm. 

'     senegae  fl. 

TTLv  to  XV 

0.30  to  I  ccm. 

*     sennae  fl. 

f  3  j  to  iv 

4  to  16  ccm. 

'     serpent,  fl. 

TTLxxx  to  Ix 

2  to  4  ccm. 

'     siraarubae  fl.     . 

fH^XV  to  XXX 

I  to  2  ccm. 

*     spigeliae  fl. 

TTIXV  to  Ix 

I  to  4  ccm. 

'     spigeliae  et  sennce  fl 

f  3  ss  to  ij 

2  to  8  ccm. 

'     stillingiae  fl. 

f  3  ss  to  ij 

2  to  8  ccm. 

'     stillingiae  comp. 

f  3  ss  to  ij 

2  to  8  ccm. 

*     stramonii  (Engl.) 

gr.  \  to  j 

0.03  to  0.05  gm. 

'     stramonii  fol.  ale. 

gr.  i  to  1 

0.02  to  0.04  gm. 

'     stramonii  seiri. 

gr.  i  to  1 

o.oi  to  0.03  gm. 

15^ 


CLIN  I  CA  L   DIA  GNOSIS. 


Dose  expressed 

in  terms  of 

Dose 

Remedies. 

apothecaries' 

expressed  in 

weights 

metric  terms. 

and  measures. 

Extr 

stramonii  fl.      . 

TTlj  to  vi 

0.05  to  0.40  ccm. 

" 

sumbul  fl. 

TT|,xv  to  Ix 

I  to  4  ccm. 

t  ( 

taraxaci   . 

gr.  V  to  XV 

0.30  to  I  gm. 

" 

taraxaci  fl. 

f  3  S3  to  ij 

2  to  8  ccm. 

t  ( 

toxicodendri  fl. 

mj  to  V 

0.05  to  0.30  ccm. 

<  1 

trifol.  prat.  fl. 

f  3  j  to  ij 

4  to  8  ccm. 

(< 

urticae  rad.  fl.  . 

TTl^V  to  XV 

0.30  to  I  ccm. 

<  ( 

ustilag.  maid.  fl. 

TT[XV  to  Ix 

I  to  4  ccm. 

" 

uvae  ursi  fl. 

TT^XXX  to  Ix 

2  to  4  ccm. 

" 

valer. 

gr.  V  to  XV 

0.30  to  I  gm. 

( < 

valer.  fl. 

Tf|,xxx  to  Ix 

2  to  4  ccm. 

" 

veratr.  vir.  fl. 

TT[ij  to  viij 

0. 10  to  0.50  ccm. 

<  1 

verbense  fl. 

TTl^XV  to  Ix 

I  to  4  ccm. 

" 

viburni  opuli  fl. 

f  3  j  to  ij 

4  to  8  ccm. 

" 

viburni  [prunifol]  fl 

f  3  j  to  ij 

4  to  8  ccm. 

" 

yerbse  santae  fl. 

f  3  i  to  3  j 

I  to  4  ccm. 

" 

zingiberis  fl. 

TIlv  to  XXX 

0.30  to  2  ccm. 

Ferr 
(( 

(< 

<  I 

<  1 

<  1 
( 1 

arsen. 

benzoas    . 

bromid.    . 

carb.  sacch. 

chlorid.    . 

citr. 

et  ammon.  citr. 

et  ammon.  sulph. 

et  ammon.  tartr. 

et  cinchonid.  citr. 

et  pot.  tartr.     . 

et  quin.  citr.     . 

et  strychnin,  citr. 

ferrocyanid. 

hypophosphis  . 

iodidum  . 

iodidum  sacch. 

lactas 

oxalas 

oxid.  hydrat.    . 

oxid.  magnet. 

phosphas 

gr.  -gV  to  \ 
gr.  j  to  V 
gr.  j  to  V 
gr.  iv  to  XV 
gr.  j  to  iij 
gr.  V  to  X 
gr.  V  to  X 
gr.  V  to  X 
gr.  V  to  XV 
gr.  V  to  X 
gr.  XV  to  Ix 
gr.  V  to  X 
gr.  j  to  XV 
gr.  iij  to  V 
gr.  V  to  X 
gr.  j  to  V 
gr.  ij  to  X 
gr.  j  to  iij 
gr.  j  to  iij 
§  ss  to  ij 
gr.  V  to  X 
gr.  i  to  V 

0.003  to  0.03  gm. 
0.05  to  0.30  gm. 
0.05  to  0.30  gm. 
0.25  to  I  gm. 
0.05  to  0.20  gm. 
0.30  to  0  60  gm. 
0.30  to  0.60  gm. 
0.30  to  0.60  gm. 
0.30  to  I  gm. 
0.30  to  0.60  gm. 
I  to  4  gm. 
0.30  to  0.60  gm. 
0.05  to  I  gm. 
0.20  to  0  30  gm. 
0.30  to  0  60  gm. 
0.05  to  0.30  gm. 
0. 10  to  0.60  gm. 
0.05  to  0.20  gm. 
0.05  to  0.20  gm. 
15  to  60  ccm. 
0.30  to  0.60  gm. 
0.05  to  0.30  gm. 

(< 

hypophosphas 

f 

r 

gr.  j  to  V 

0.05  lo  0.30  gm, 

DOSE    TABLE. 


DJ 


Dose    expressed 

in  terms  of 

Dose 

Remedies. 

apothecaries' 

expressed  in 

weights 

metric    terms. 

and  measures. 

Ferri  sub-carb.           .... 

gr.  V  to  XXX 

0.30  to  2  gm. 

"     sulphas    . 

gr.  j  to  iij 

0.05  to  0.20  gm. 

"     sulphas  exsiccat. 

gr.  i  to  li 

0.03  to  0.08  gm. 

"     valer. 

gr.  j  to  iij 

0.05  to  0.20  gm. 

Ferrum  ammoniat.    , 

gr.  V  to  X 

0.30  to  0.60  gm. 

dialys. 

TT[j  to  XV 

0.05  to  I  ccm. 

'•       redact. 

gr.  j  to  V 

0.05  to  0.30  gm. 

Filix  mas 

3  j  to  ij 

4  to  8  gm. 

Fuchsine  . 

gr.  j  to  iij 

0.05  to  0.20  gm. 

Galla 

gr.  X  to  XX 

0.60  to  1.20  gm. 

Gambogia 

gr.  ij  to  iij 

0. 10  to  0.20  gm. 

Gentiana 

gr.  X  to  XXX 

0.60  to  2  gm. 

Guarana   . 

gr.  V  to  XXX 

0.30  to  2  gm. 

Hydrarg.  c.  creta 

gr.  V  to  X 

0.30  to  0.60  gm. 

"         chlor,  cor  res. 

gr.  ^  to  iV 

O.ooi  to  0.005  gn^. 

"         chlorid.  mite 

gr.  1  to  viij 

O.OI  to  0.50  gm. 

"         Cyanid. 

gr.  iV  to  i 

0.004  to  0.03  gm. 

"         iodid.  flav. 

gr.  i  to  j 

O.OI  to  0.05  gm. 

"         iodid.  rubr. 

gr.  A  to  i 

0.004  to  0.03  gm. 

"         iodid.  vir. 

gr.  i  to  j 

O.OI  to  0.05  gm. 

"         oxid.  flav. 

gr.  j\  to  i 

0.004  to  0.03  gm. 

"         oxid.  nigr. 

gr.  iV  to  j 

0.005  to  0.05  gm. 

"         oxid.  rubr. 

gr.  iV  to  i 

0.004  to  0.03  gm. 

"         subsulphas  flav. 

gr.  i  to  j 

0.015  to  0.05  gm. 

"         sulphureL.  nigr. 

gr.  V  to  X 

0.30  to  0.60  gm. 

"         sulphuret.  rub. 

gr.  V  to  X 

0.30  to  0  60  gm. 

"         c.  magn.     . 

gr.  V  to  X 

0.30  to  0.60  gm. 

Infusum  brayerae 

1  !  ij  to  viij 

60  to  250  ccm. 

"        buchu 

f!ij 

60  ccm. 

"         digitalis 

f  3  ij  to  iv 

8  to  16  ccm. 

"         eupatorii 

f!ij 

60  ccm. 

"         sennse  comp. 

f !  j  toij 

30  to  60  ccm. 

ulmi    . 

Aä  libitum. 

Ad  libitum. 

lodinum   .          .          ,          . 

gr.  I  to  j 

0.015  to  0.05  gm. 

lodoformum 

gr.  j  to  iij 

0.05  to  0.20  gm. 

Ipecacuanha  expect. 

gr.  i  to  j 

O.OI  to  0.05  gm. 

"            emet.     . 

gr.  XV  to  XXX 

I  to  2  gm. 

Jalapa 

gr.  XV  to  XXX 

I  to  2  gm. 

Juniperi  baccae 

3  j  to  ij 

4  to  8  gm. 

Kairine     .... 

gr.  ij  to  X 

0. 10  to  0.60  gm. 

154 


CLINICAL   DIAGNOSIS. 


Dose   expressed 

in  terms  of 

Dose 

Remedies. 

apothecaries' 

expressed  in 

weights 

metric  terms. 

and  measures. 

Kino 

gr.  X  to  XXX 

o.6o  to  2  gm. 

Krameria 

. 

gr.  X  to  XXX 

o.6o  to  2  gm. 

Lacto-pepline   . 

. 

gr.  X 

o.6o  gm. 

Lactucaiium 

. 

gr.  iij  to  X 

0.20  to  o.6o  gm. 

Liq.  ammon.  acet.     . 

. 

f  S  ij  to  viij 

8  to  25  ccm. 

"     acidi  arseniosi  . 

iq^ij  to  vij 

0. 10  to  0.50  ccm. 

"     arsen.  ethydr.  iod. 

(Donovan's  sol.) 

TTlij  to  vij 

o.io  to  0.50  ccm. 

"     ferri  chloridi 

TTlij  to  X 

o.io  to  0.60  ccm. 

"     ferri  dialys. 

■rT[j  to  XV 

0.05  to  I  ccm. 

"     ferri  nitrat. 

. 

TTlv  to  XV 

0.30  to  I  ccm. 

"     pepsini 

f  3  ij  to  iv 

8  to  16  ccm. 

"     potassse     . 

TT^V  to  XXX 

0.30  to  2  ccm. 

"     potassii  arsenit.  (F 

owler's  solution) 

TT[iij  to  vij 

0.20  to  0.50  ccm. 

"       potassii  citrat. 

f  3  ij  to  iv 

8  to  16  ccm. 

"     sodse 

Tr[v  to  XXX 

0.30  to  2  ccm. 

' '     sodii  arseniatis  (Pearson's  solution) 

TT^iij  to  vij 

0.20  to  0.50  ccm. 

Lithii  benzoas  . 

gr.  ij  to  v 

O.IO  to  0.30  gm. 

"      bromid.  . 

gr.  i  to  iij 

0.05  to  0.20  gm. 

"      carb. 

gr.  ij  to  vi 

O.IO  to  0.40  gm. 

"      citr. 

gr.  ij  to  V 

O.IO  to  0.30  gm. 

"      salicylas 

gr.  ij  to  viij 

O.IO  to  0.50  gm. 

Lobelia     . 

gr.  V  to  X 

0.30  to  0.60  gm. 

Lupulinum 

gr.  V  to  X 

0.30  to  0.60  gm. 

Magnesia 

gr.  XV  to  Ix 

I  to  4  gm. 

Magnesii  carb. 

gr.  XV  to  Ix 

I  to  4  gm. 

"          citr.  gran. 

3  j  to  viij 

4  to  32  gm. 

"          sulphas 

3  j  to  viij 

4  to  32  gm. 

"          sulphis 

gr.  v  to  XXX 

0.30  to  2  gm. 

Manganesii  oxid.  nig 

r. 

(binoxid.) 

gr.  ij  to  X 

O.IO  to  0.60  gm. 

sulphas 

. 

gr.  ij  to  X 

O.IO  to  0.60  gm. 

Manna 

f  i  to  ij 

30  to  60  gm. 

Massa  copaibae 

gr.  V  to  XXX 

0.30  to  2  gm. 

*'     ferri  carb. 

gr.  v  to  XV 

0.30  to  I  gm. 

"     hydrarg. 

gr.  i  to  XV 

0.05  to  I  gm. 

Mist  ammoniaci 

f  3  iv  to  viij 

15  to  30  ccm. 

"     asafoetidse 

f  3  iv  to  viij 

15  to  30  ccm. 

"     chloroformi 

f  3  iv  to  viij 

15  to  30  ccm. 

"     cretae 

f!Jtoij 

30  to  60  ccm. 

"     ferri  comp. 

f  3  ss  to  ij 

15  to  60  ccm. 

"     ferxi  at  ammon 

acet. 

f  1  ss  to  j 

15  to  30  ccm. 

DOSE    TABLE. 

155 

Dose   expressed 

in  terms  of 

'  Dose 

Remedies. 

apothecaries' 

expressed  in 

weights 

metric  terms. 

and  measures. 

Mist  glycyrrh.  comp. 

f  3  j  to  iv 

4  to  16  ccm. 

"     magnes.  et  asafoet.    . 

f  3  j  to  iv 

4  to  16  ccm. 

"     potassii  citn 

f  1  ss  to  ij 

15  to  60  ccm. 

' '     rhei  et  sodse 

f  §  ss  to  j 

15  to  30  ccm. 

Morphiae  murat. 

gr.  i  to  i 

o.oi  to  0.03  gm. 

sulph. 

gl--  i  to  1 

0.008  to  0.03  gm. 

"         acetat. 

gr.  i  to  i 

0.01  to  0.03  gm. 

"         sulph.  liq.  . 

f  3  j  to  iv 

4  to  16  ccm. 

"         sulph.  liq.  (Magendie 

TTl,ij  to  XV 

O.IO  to  I  ccm. 

Moschus  .... 

gr.  V  to  X 

0.30  to  0.60  gm. 

Myrrha     .... 

gr.  X  to  XX 

0.60  to  1.20  gm. 

xNapthalin 

gr.  j  to  ij 

0.05  to  O.IO  gm. 

Xarceina  .... 

gr.  \  to  ij 

O.OI  to  O.IO  gm. 

Nicotia     .... 

gr.  eV  to  jV 

o.ooi  to  0.025  gm. 

N  itro-glycerinum 

gr.  in  to  A 

0.00 1  to  0.004  g'^^. 

Nux  vomica 

gr.  j  to  V 

0.05  to  0.30  gm. 

Oleoresina  asphidii    . 

gr  XV  to  Ix 

I  to  4  gm. 

"          capsici     . 

gr.  i  to  i 

0.01  to  0.03  gm. 

"          cubebae    . 

' 

gr.  V  to  XXX 

0.30  to  2  gm. 

"          lupulini    . 

gr.  ij  to  V 

O.IO  to  0.30  gm. 

"          piperis     . 

gr.  i  to  iij 

0.05  to  0.20  gm. 

"          zingiberis 

gr.  j  to  iij 

0.05  to  0.20  gm. 

Oleum  amygdal  amar. 

Tflitoi 

0.008  to  0.015  ccm. 

"       anisi 

TTiij  to  V 

O.IO  to  0.30  ccm. 

"       cajuput 

TTiij  to  V 

O.IO  to  0.30  ccm. 

"       chenopodii 

■nivto  X 

0.30  to  0.60  ccm. 

"       copaibse 

TUviij  to  XV 

0. 50  to  I  ccm. 

"       cubebae 

TT[XV  to  XXX 

I  to  2  ccm. 

"       eriger     . 

TT1,V  to  XV 

0.30  to  I  ccm. 

"       eucalypti 

TF\,x  to  XXX 

0.60  to  2  ccm. 

limon.    . 

TTLij  to  iv 

O.IO  to  0.20  ccm. 

"       morrhuse 

f  3  j  to  iv 

4  to  16  ccm. 

*'       olivae      .         .         . 

f  3  j  to  iv 

4  to  16  ccm. 

' '       phosphoratum 

gr.  j  to  iij 

0.05  to  0.20  gm. 

"       ricini 

f  §  j  to  iv 

4  to  32  ccm. 

"       sabinse  . 

TTlj  to  iij 

0.05  to  0.20  ccm. 

"       terebinth. 

TT|,  V  to  XXX 

0.30  to  2  ccm. 

"       tiglii       . 

Tn,itoi 

0.01  to  0.08  ccm. 

Opium,  14  %  morphine 

gr.  \  to  4 

O.OI  to  0.08  gm. 

Pareira      .         .         ,         , 

3  ss  to  j 

2  to  4  gm. 

156 


CLnXICAL    DIAGXOSIS. 


Dose   expressed' 

in  terms  of     i 

Dose 

Remedies. 

apothecaries'    ■ 

expres>ed  in 

weights         ! 
and  measures. 

metric  terms. 

Paraldehyd. 

Tllxx  to  xl 

I.20  to  2.40  ccm. 

Pelletierine 

gr.  V  to  XV 

0.30  to  I  gm. 

Pepsinum  purum 

gr.  XV  to   1  ss 

I  to  15  gm. 

"         saccharatum 

gr.  XXX  to   3  j 

2  to  30  gm. 

Petroleum 

3  ss  to  j 

2  lo  4  gra. 

Phosphorus 

gr.  T-k  to  ^V 

0.0005  to  0.003  gm. 

Physostigminse  salicyl 

gr.  ^l^  to  Jj, 

0.0005  to  0.003  gm. 

' '               sulphas 

gr.  3-k  lo  -h 

0.0005  to  0.003  gm. 

Picrotoxinum     . 

C-  eV  to  I 

o.ooi  to  0.02  gm. 

Pilocarpina  and  salts 

gl--  -^4  to  i- 

o.ooi  to  0.03  gm. 

Pil.  aloes 

pil.  j  to  iij 

pil.  j  to  iv 

' 

aloes  et  asafoet. 

"    ij  to  V 

"    ij  to  v 

' 

aloes  et  ferri 

"    j  to  iij 

"    j  to  iij 

• 

aloes  et  mast. 

"    j  to  iij 

"    j  to  iij 

1 

aloes  et  myrrhs 

"    ij  to  V 

"    ij  to  V 

• 

antim,  comp. 

"    j  to  iij 

"    j  to  iij 

( 

asafoetidse  . 

"    j  to  vj 

"    j  to  vj 

< 

cathart.  comp.    . 

"    j  to  iv 

"    j  to  iv 

• 

ferri  comp. 

*  "    ij  to  v 

"    ij  to  v 

• 

ferri  iodidi 

"    j  to  iv 

"    j  to  iv 

• 

galbani  comp. 

"    j  to  V 

"    j  to  V 

• 

hydrarg. 

gr.  S3  to  XV 

0.025  to  I  gm. 

• 

opii    . 

pil.  j  to  ij 

pil.  j  to  ij 

i 

phosphor!  . 

"    j  to  iv 

"    j  to  iv 

( 

rhei    . 

"    ij  to  V 

"    ij  to  v 

"   rhei  comp. 

' '    ij  to  V 

"    ij  to  V 

Piperinum 

"    gr.  j  to  viij 

0.05  to  0.50  g[n. 

Plumbi  acetas   . 

gr.  i  to  iij 

0.03  to  0.20  gm. 

' '       iodidum 

gr.  \  to  iij 

0.03  to  0.20  gm. 

Potassii  acetas  . 

gr.  XV  to  Ix 

I  to  4  gm. 

"       bicarb. 

gr.  v  to  Ix 

0.30  to  4  gm. 

''       bichromat.    . 

gr.  i  to  i 

o.oi  to  0.25  gm. 

'  *       bitartr. 

gr.  j  to  ij. 

0.05  to  0.40  gm. 

"       bromid. 

gr.  v  to  Ix 

0.30  to  4  gm. 

"       carb.    . 

gr.  V  to  XXX 

0.30  to  2  gm. 

"       chloras 

gr.  V  to  XXX 

0.30  to  2  gm. 

"       citras    .          .         , 

gr.  XV  to  Ix 

I  to  4  gm. 

"       Cyanid, 

gr-  tV  to  1 

0.004  to  o.ooS  gm 

"       et  sodii  tartr. 

3  i-  to  j 

15  to  30  gm. 

"       ferrocyanid. 

. 

gr.  X  to  XV 

0.60  to  I  gm. 

DOSE    TABLE. 


157 


Dose   expressed 

in  terms  of 

Dose 

Remedies. 

apothecaries' 

expressed  in 

weights 

metric  terms. 

and  measures. 

Potassii  hypophosphis 

gr.  V  to  XV 

0.30  to  I  gm. 

"       iodid.   . 

gr.  ij  to  XV 

0. 10  to  I  gm. 

"       nitras  . 

gr.  V  to  XV 

0.30  to  I  gm. 

"       permanganat. 

gr.  ss  to  j 

0.03  to  0.06  gm. 

"       sulphas 

3  j  to  iv 

4  to  16  gm. 

"       sulphidum    . 

gr.  j  to  X 

0.05  to  0.60  gm. 

"       sulphis 

gr.  XV  to  XXX 

I  to  2  gm. 

"       sulphuret 

gr.  ij  to  _vj 

0. 10  to  0.40  gm. 

tartras 

3  j  to  viij 

4  to  30  gm. 

Prunus  Virginia 

3  ss  to  j 

2  to  4  gm. 

Pulv.  antimonialis    . 

gr.  iij  to  X 

0.20  to  0,60  gm. 

"    aromat.    . 

gr.  V  to  XXX 

0.30  to  2  gm. 

"    cretae  comp. 

gr.  V  to  XXX 

0.30  to  2  gm. 

"    glycyrrrh.  comp. 

gr.  XXX  to  Ix 

2  to  4  gm. 

"    ipecac,  et  opii  (Dover) 

gr.  V  to  XV 

0.30  to  I  gm. 

"    jalapa  comp.     . 

gr.  xxx  to  Ix 

2  to  4  gm. 

"    morphinse  comp. 

gr.  V  to  XV 

0.30  to  I  gm. 

"    rhei  comp. 

gr.  XXX  to  Ix 

2  to  4  gm. 

Quinidina  (and  salts) 

gr,  j  to  xxx 

0.05  to  2  gm. 

Quinina  (and  salts)    . 

gr.  j  to  xxx 

0.05  to  2  gm. 

Quininae  arsenias 

gr-  \  to  j 

o.oi  to  0.05  gm. 

Resina  copaibae 

gr.  ij  to  x 

o.io  to  0.60  gm. 

"       jalapae 

gr.  ij  to  V 

o.io  to  0.30  gm. 

"        podophylli   . 

gr-  \  to  \ 

0.008  to  0.03  gm. 

"        scammonii    . 

gr.  ij  to  x 

O.IO  to  0.60  gm. 

Resorcin  ..... 

gr.  V  to  xxx 

0.30  to  2  gm. 

Rheum     . 

gr.  ij  to  XXX 

O.IO  to  2  gm. 

Sabina 

gr.  V  to  X 

0.30  to  0.60 

Salicinum 

gr.  V  to  XXX 

0.30  to  2  gm. 

Santoninum 

gr.  j  to  V 

0.05  to  0.30  gm. 

Sapo 

gr.  V  to  XXX 

0.30  to  2  gm. 

Scammonium 

gr.  iij  to  XV 

0.20  to  I  gm. 

Scilla 

gr.  i  to  ij 

0.05  to  O.IO  gm. 

Senega 

gr.  X  to  XX 

0.60  to  1.20  gm. 

Senna 

gr.  V  to  Ix 

0,30  to  4  gm. 

Serpentaria 

3  j  to  ij 

4  to  8  gm. 

Sinapis 

3ij 

8  gm. 

Sodii  acetas 

gr.  XV  to  Ix 

I  to  4  gm. 

' '     arsenias 

gr.  Jj  to  iV 

o.ooi  to  0.005  gm. 

"     benzoas 

gr.  V  to  XV 

0.30  to  I  gm. 

158 


CLINICAL  DIAGNOSIS. 


Remedies. 


Sodii  bicarb.     . 

•'     bi  sal  phis 

' '     boras 
bromid    . 
carb. 

"     carb.  exsicc. 

' '     chloras 

' '     hypophosphis 

' '     hj^osulpbis 

"     iodidum  . 

' '     phosphas 

"     salicylas  . 

' '     santonin  as 

' '     sulpbas 

*'     sulphis 
Sparteinse  sulph. 
Spigelia    . 
Spir.  sether.  comp. 

"     aether,  nitrosi 

' '     ammoniae 

"     am^moniae  arom 

' '     camphors 

' '     chlorof  ormi 

"     lavend.  comp. 

"     menth.  pip. 
Stramonii  folium 
Sirychnina  and  salts 
Siyrax 
Sulphur 
Syr.  acidii  hydriodidi  allii 

*'     calcii  lactophos 

' '     calcis 

"     ferri  bromidi 

"     ferri  iodidi 

"     ferri  oxidi 

"     ferri  hypophosph 

"     fer.  quin,  et  str.  phos 

"     hypophosphit. 

"     hypophosph.  c.  fer. 

"     ipecac. 


Dose   expressed 

in  terms  of 
apothecaries' 

weights 
and  measures 


V  to  XXX 

V  to  XXX 

V  to  XXX 

V  to  XXX 

V  to  XXX 

V  to  XV 

V  to  XXX 

V  to  XV 

V  to  XXX 

V  to  XV 

ij  to  y:^ 

V  to  XXX 

gr.  ij  to  X 
gr.  j  to  ij 

V.   to  XXX 


gr. 
gr. 
gr. 
gr. 
gr- 
gr- 
gr. 
gr. 
gr. 
gr. 
gr- 


1  to  i 

4    "^^    2 


gr. 
gr. 
gr.  X  to  I  j 

TTl,  XXX  to  Ix 

f  3  ss  to  ij 

TTl,  V  to  XXX 
TTl,  XV  to  XXX 
Tli  V  to  XXX 
TTl  XV  to  Ix 
TTl,  XXX  to  Ix 
TTL  XXX  to  Ix 
gr.  j  to  ij 
gr.  :^  to  ^a^ 
gr.  X  to  XX 
3  ss  to  iv 
f  3  j  to  iv 
f  3  j  to  ij 

ni  XV  to  XXX 

TTl  XV  to  Ix 

m  XV  to  Ix 

f  3j 

f3j 

f3j 

f3j 

f2j 

f  3  ss  to  iv 


Dose 

expressed  in 

metric  terms. 

1 

0.30  to  2  gm. 

0.30  to  2  gm 

0.30  to  2  gm 

0.30  to  2  gm 

0.30  to  2  gm 

0.30  to  I  gm 

0.30  to  2  gm 

0.30  to  I  gm 

0.30  to  2  gm 

0.30  to  I  gm 

0. 10  to  I  gm 

0.30  to  2  gm 

o.io  to  0.60  gm. 

0.05  to  0.10  gm. 

0.30  to  2  gm. 

o.oi  to  0.03  gm. 

0.60  to  30  gm. 

2  to  4  ccm. 

2  to  8  ccm. 

0.30  to  2  ccm. 

I  to  2  ccm. 

0.30  to  2  ccm. 

I  to  4  ccm. 

2  to  4  ccm. 

2  to  4  ccm. 

0.05  to  O.IO  gm. 

o.ooi  to  0.005  gin. 

0.60  to  1.20  gm. 

2  to  16  gm. 

4  to  16  ccm. 

4  to  8  ccm. 

I  to  2  ccm. 

I  to  4  ccm. 

I  to  4  ccm. 

4  ccm. 

4  ccm.                   1 

'4  ccm. 

4  ccm. 

4  ccm. 

2  to  16  ccm. 

DOSE    TABLE. 


159 


Dose  expressed 

in  terms  of 

Dose 

Remedies. 

apothecaries' 

expressed  in 

weights 

metric  terms. 

and  measures. 

:>yr.   krameri^e            .... 

f  3  SS  to  iv 

2  to  16  ccm. 

lactucarii 

f3j 

to  iij 

4  to  12  ccm. 

pruni  virginianse 

f3j 

to  ij 

4  to  8  ccm. 

rhei 

f3j 

to  iv 

4  to  16  ccm. 

rhei  arom. 

f3j 

to  iv 

4  to  16  ccm. 

rosae 

f3j 

to  ij 

4  to  8  ccm. 

rubi 

f3j 

to  ij 

4  to  8  ccm. 

sarsap.  comp.    . 

f  3  j  to  iv 

4  to  16  ccm. 

Scillae 

f  3  ss  to  j 

2  to  4  ccm. 

Scillae  comp,  (hive-sirup) 

Tr|,  XV  to  Ix 

I  to  4  ccm. 

senegse 

f  3  j  to  ij 

4  to  8  ccm. 

"     sennse 

f  3  j  to  iv 

4  to  16  ccm. 

Testa  prasparata 

gr.  V  to  XX 

0.30  to  1.20  gm. 

Thallin     .... 

gr.  iv  to  viij 

0.25  to  0.50  gm. 

Tiiict.  aconiti  fol. 

TTLviij  to  xvj 

0.50  to  I  ccm. 

'       aconiti  rad.     . 

TTljtO  V 

0.05  to  0  30  ccm. 

'      Jicon.  rad.  (Flemings) 

TT[|  to  ijSS 

0.04  to  0.15  ccm. 

'       aloes  (18S0)     . 

f  3  ss  to  ij 

2  to  8  ccm. 

'       aloes  et  myrrhae 

f  3  i  to  ij 

4  to  8  ccm. 

'       arnicce  flor.     . 

Tllv  to   XXX 

0.30  to  2  ccm. 

'      arnicoe  rad.     . 

TTI,XV  to  XXX 

I  to  2  ccm. 

'       asafcetidse 

TT|,xxx  to  Ix 

2  to  4  ccm. 

'      belladonnce     . 

Tr[v  to  XV 

0.30  to  I  ccm. 

calumbee 

f  3  i  to  iv 

4  to  16  ccm. 

'      cannabis  ind. 

TT[XV  to  XXX 

I  to  2  ccm. 

'      cantharid. 

TTlv  to  XV 

0.30  to  I  ccm. 

'      capsici    . 

TTl,V  to  XV 

0.30  to  I  ccm. 

cardamomi 

f3i 

4  ccm. 

'      cardamomi  comp.   . 

f3i 

4  ccm. 

*       catechu  comp. 

f  3  ss  to  ij 

2  to  8  ccm. 

'       Cimicifugae 

TTlxxX  to  Ix 

2  to  4  ccm. 

'       cinchonae 

f  3  ss  to  ij 

2  to  8  ccm. 

'       cinchonae  comp. 

f  3  ss  to  ij 

2  to  8  ccm. 

'       colchici  rad.    . 

TTLv  to  XV 

0.30  to  I  ccm. 

'      colchici  sem. 

Tn^v  to  XV 

0.30  to  I  ccm. 

'      conii 

TTlv  to   XXX 

0.30  to  2  ccm. 

'      cubebce  . 

f  3  j  to  ij 

4  to  8  ccm. 

'       digitalis 

TiXv  to  XV 

9.30  to  r  ccm. 

'      ferri  acet. 

Tri,xv  to  XXX 

I  to  2  ccm. 

*      ferri  chloridi 

TTlx 

to  Ix 

0.60  to  4  ccm. 

i6o 


CLINICAL  DIAGNOSIS. 


Dose  expressed 

in  terms  of 

Dose 

Remedies. 

apothecaries* 

expressc'l  in 

weights 

metric  term,. 

and  measures. 

Tinct.  ferii  chloricli  aether. 

ITixV  to  XXX 

I  to  2  ccm. 

'      ferri  pomati    . 

TTLxv  to  Ix 

I  to  4  ccm. 

gallse 

f  3  ss  to  ij 

2  to  8  ccm. 

'      gelsemii 

Tllv  to  XV 

0.30  to  I  ccm. 

'      gentian  comp. 

f  3  ss  to   3  ij 

2  to  8  ccm. 

'      guaiaci   . 

TTixxx  to  Ix 

2  to  4  ccm. 

'      guaiaci  ammon. 

TUxxx  to  Ix 

2  to  4  ccm. 

'      hellebori 

TTix  to  XV 

0.30  to  I  ccm. 

'      humuli   . 

f  3  j  to  ij 

4  to  8  ccm. 

'      hydrastis 

TTLxxx  to  xc 

2  to  6  ccm. 

*      hyoscyami  fol. 

TTLxv  to  Ix 

I  to  4  ccm. 

'      hyoscyami  sem. 

TTl,xv  to  XXX 

I  to  2  ccm. 

'      ignati^  . 

TT[V  to  XV 

0.30  to  I  ccm. 

'      iodini     . 

TTlv  to  X 

0.30  to  0.60  ccm. 

'       iodini  comp.   . 

TTiij  to  X 

0.12  to  0.60  ccm. 

'      ipecac,  et  opii 

TT[v  to  XV 

0.30  to  I  ccm. 

'      jalapse    . 

f  3  ss  to  ij 

2  to  8  ccm. 

'      kino 

f  3  ss  to  ij 

2  to  8  ccm. 

'      kramericC 

f  3  ss  to  ij 

2  to  8  ccm. 

'      lavend.  comp. 

f  3  ss  to  ij 

2  to  8  ccm. 

'      lobelias  . 

"n[xv  to  xlv 

I  to  3  ccm. 

'      lupulini . 

f  3  ss  to  ij 

2  to  8  ccm. 

'      matico    . 

f  3  ss  to  ij 

2  to  8  ccm. 

'      moschi   . 

TT[xv  to  Ix 

T  to  4  ccm. 

'      myrrhae 

f  3  ss  to  j 

2  to  4  ccm. 

'      nuc.  vomicae   . 

TFi,v  to  xlv 

0.30  to  3  ccm. 

'      opii 

TT^v  to  XV 

0.30  to  I  ccm. 

'      opii  camph.     . 

niv  to  Ixxv 

0.30  to  5  ccm. 

*      phytolaccce 

TUv  to  Ix 

0.30  to  4  ccm. 

'       physostigmatis 

Tri,v  to  XV 

0.30  to  I  ccm. 

'      quassiae 

f  3  ss  to  ij 

2  to  8  ccm. " 

'      rhei 

f  3  j  to  viij 

4  to  30  ccm. 

'      rhei  arom. 

TT|,xxx  to  Ixxv 

2  to  5  ccm. 

'      rhei  dulc. 

f  3  j  to  iv 

4  to  16  ccm. 

'      sanguinarias    . 

Tr|,xv  to  Ix 

I  to  4  ccm. 

*      Scillae 

TTLv  to  Ix 

0.30  to  4  ccm. 

*      serpentariae     . 

f  3  ss  to  ij 

2  to  8  ccm. 

'       stramon.  fol. 

TT^v  to  XV 

0.30  to  I  ccm. 

'       stramon.  sem. 

TTlv  to  XV 

0.30  to  I  ccm. 

'       strophanthi     . 

Tltij  to  vj 

o.io  to  0.40  ccm. 

DOSE    TABLE. 


I6l 


Dose    expressed 

in  terms  of 

Dose 

Remedies. 

apothecaries' 

expressed  in 

weights 

metric  terms. 

and  measures. 

Tinct.  sumbul.            .... 

TT1,V  to  XXX 

0.30  to  2  ccm. 

' '      valer. 

f  3  ss  to  ij 

2  to  8  ccm. 

'■       valer.  ammon 

f  3  ss  to  ij 

2  to  8  ccm. 

"      veratr.  vir. 

Tiliij  to  X 

0.20  to  0.60  ccm. 

' '       zingiberis 

Tr|,xv  to  Ix 

I  to  4  ccm. 

Trinitrine  (nitroglyce 

jrine) 

TTlj  to  iij 

0.05  to  0.20  ccm. 

Ureihan    . 

gr.  XV  to  Ix 

I  to  4  gm. 

Uva  ursi  . 

3  ss  to  j 

2  to  4  gm. 

Verat.  alb. 

gr.  j  to  iij 

0.05  to  0  20  gm. 

Veratria    . 

gr-  iV  to  i 

0.005  to  0.02  gm. 

Zinci  acet. 

gr.  j  to  ij 

0.05  to  o.io  gm. 

"     bromid. 

gr.  \  to  ij 

0.03  to  o.io  gm. 

' '     Cyanid. 

gr-  iV  to  i 

0.055  to  0.015  gm. 

' '     iodid. 

gr.  \  to  iij 

0.03  to  0.20  gm. 

' '     oxid. 

gr.  I  to  X 

0.05  to  0.60  gm. 

' '     phosphid 

gr-  iV  to  i 

0.005  to  o.oi  gm. 

"     sulphas  (emetic) 

gr.  XV  to  XXX 

I  to  2  gm. 

"     valerianas 

gr.  j  to  v 

0.05  to  0.30  gm.] 

INDEX. 


Abbe's  condenser,  105 

Abdomen,  62 

Acarus  folliculorum,  loi 

"      scabiei,  100 
Acetone,  85 

"         test  for,  85 
Achorion  Schoenleinii,  loi 
Acid,  amido-caproic,  87 
*'     a  m  i  d  o-hydroparacumaric, 

aromatic  oxi-,  73 
carbolic,  73 
carbonic,  75 
chrysophanic,  89 
diacetic,  86 
hippuric,  73 
hydrochloric,  74 
muriatic,  74 
oxalic,  73 
phosphoric,  75 
sulphuric,   75 

"  test  for,  75 

uric,  71 
"     test  for,  73 
Actinomycosis,    examination   of, 
107 
"  in  sputum,  36 

^gophony,  30 
Air,  complemental,  21 
"     ordinary  breathing,  21 
"    reserve,  21 
"    residual,  21 
Albumen,  77 

**  acetic  acid  and  ferro- 

cyanide  of  potassium, 
test  for,  78 
"  amount  used,  136 

"  "        set  free,  136 


Albumen,  biuret  test  for,  78 
"  heat  test  for,  77 

"  Heller's  test  for,  77 

"  picric  acid  test  for,  78 

Ammonia,  76 

"  test  for,  132 

Amoeba  coli,  loi 

Anaemia,       progressive       perni- 
cious,  7 
"        secondary,  6 

Anaesthesia,  108 

Analgesia,  no 

Anasarca,  92 

Anguillula  intestinalis,  gg 

Angulus  Ludovici,  16 

Aniline  colors,  104 

Ankylostomum  duodenale,  gg 

Anode,  115 

Apnoea,  20 

Arthropodes,  100 

Ascaris  lumbricoides,  g8 

Ascites,  92 

Aspergillus  glaucus,  102 
"  niger,  102 

"  threads  in  sputum,  36 

Ataxia,  II2 

Auscultation,  27 

Balantidium  or  paramaecium  coli, 

lOI 

Bacillus  anthracis  in  sputum,  36 
Bacillus  or  rod,  102 
Bacteria,  102 
Biermer,   26 
Bile,  80 

"     coloring  matter  of,  80 
Bilirubin,  80 

"         Gmelin's  test  for,  80 


163 


164 


CLINICAL  DIAGNOSIS. 


Biliverdin,  80 
Biuret  reaction,  70 
Bizzozero,  3 
Bladder,  67 

Blood,    amount    of   haemoglobin 
in,  I 
"      bacilli  anthracis  in,  7 
*'  "      leprae  in,  7 

"       examination  of  the,  4 
"       micro-organisms  in,  7 
"      quantity  of,  i 
"      reaction  of,  I 
"       specific  gravity  of,  I 
"       spirilla  of  recurrent  fever 

in,  7 
"      tubercle  bacilli  in,  7 
"      in  urine,  79 
Blood  corpuscles,  dwarf,  2 
"  "    enumeration  of,  5 

"    giant,  2 
"  "    proportion  between 

red  and  white,  5 
Blood-plaques,  3 
Blood-vessels,  auscultation  of,  48 
Bothriocephalus  latus,  97 
Bouchut,  5 

Brain  and  spinal  cord,  124 
Breast,  chicken,  16 
"        cobbler's,  16 
"        funnel,  16 
Breathing  sound,  27 

"         amphoric,  27,  28 
"         bronchial,  27,  28 
"         changes    in    the    fre- 
quency of,  20 
"         increase    in    the    fre- 
quency of,  20 
"         undetermined,   27,  28 
"         vesicular,  27 
Bronchophony,  29 
Bruit  de  pot  fele,  21 
Burdach,  123 

Calcium,  76 

"        sulphate  of,  76 
Calculi,  faecal,  134 

"        salivary,  134 
Casts  in  urine,  90 
Centre  for  arm,  124 


Centre  for  face,  124 
leg,  124 
"  sense  of  sight,  124 

"  speech,  124 

Cercomonas  intestinalis,  loi 
Cestodes,  96 
Charcot,  36,  65 
Chest,  circumference  of,  18 
"       enlargement  of,  18 
"       topography  of,  16 
Cheyne,  20 

Cheyne-Stokes  respiration,  20 
Chicken-pox,   12 
Chlorosis,  7 
Choletelin,  80 
Choreic  movements,  113 
Clavicle,  16 
Clonus,  foot,  122 

"       patellar,  122 
Coccus,  102 

Coefiicient  of  Häser,  68 
Concrements,     analysis    of     the 
pathological,  132 
"  urinary,  132 

Condenser,  Abbe's,  105 
Convulsions,  112 
Creatinine,  73 
Cressol,  73 
Crisis,  9 

Crystals,      Charcot-Leyden,     in 
sputum,  36 
*'         Cholesterine,     in     spu- 
tum, 36 
' '         fatty  acid,  in  sputum,  35 
"         leucine,  in  sputum,  36 
"         tyrosine,  in  sputum,  36 
Current,  constant,  113 
"        density  of,  113 
"        faradic,  113 
"        galvanic,  113 
"        intensity  of,  113 
"        interrupted,    113 
"        strength  of,  113 
Curschmann,  35 
Cypho-scoliosis,  16 
Cyphosis,  16 
Cysticercus  cellulosae,  97 
Cystin,  133 

•'      test  for,  133 


INDEX. 


165 


Dextrose,  81 

"         bismuth  test  for,  84 
"         Böttger's  test  for,  84 
"         Fehling's  test  for,  83 
"         fermentation  test  for, 

81 
"         Moore's  test  for,  82 
Mulder's  test  for,  84 
"         Phenylhydrazin        test 

for,  84 
"         polarization  test  for,  8  5 
"         quantitative  test  for,  83 
"         reduction  tests  for,  82 
"         Trommer'stest  for,  82 

Diacetic  acid,  86 

"      test  for,  86 

Diagnosis,  by  means  of  electrici- 
ty, 113 

Diazoreaction,  86 

Diet  of  sustenance,  136 

Distomum  haematobium,  100 
"  hepaticum,  100 

"  lanceolatum,  100 

Dose  table,  144 

Dubrisay,  5 

Ductus  arteriosus  Botalli,  44 

Dulness,  cardiac,  43 

Duperie,  5 

Dyspnoea,  19 

"  expiratory,  19 

"  inspiratory,  19 

"  mixed  form  of,  20 

Ehrlich,  3,  4,  105 
Electrodes,  113 

Elementary  granular  masses,  3 
Eosinophile  cells,  4 
Epithelium,  alveolar,  in  sputum, 

34 
"  cylindrical,  in   spu- 

tum, 34 
"  pavement,    in    spu- 

tum, 34 
"  in  sputum,  89-90 

Erysipelas,  15 
Ewald,  57 
Exner,  39 

Fastigium,  g 
Fat  87 


Favus  fungus,  loi 
Faeces,  63 

"       in  cholera,  65 

"       color  of,  64 

"       consistence  of,  63 

"       crystals  in,  65 

"of  Charcot-Neu- 
mann  in,  65 

"       digestive  juices  in,  63 

"       in  dysentery,  65 

"       epithelium  in,  66 
fat  in,  65 

"       leucocytes  in,  65 

"       micro-organisms.  66 

"       mucus  in,  64 

"       products  of  excretion  in, 

63 
"       red-blood   corpuscles  in, 

"       remains  of  food  in,  63,  65 
"       in  typhoid  fever,  65 
Febris  continua,  9 

"       intermittens  9,  14 
"      recurrens,  13 
"       remittens,  9 
Fermentation  tubes,  82 
Fever,  considerable,  8 
"      high,  8 
"      intermittent,  14 
"      malarial,  14 
•  "      moderate,  8 
*'      recurrent,  13 
"      scarlet,  10 
"      slight,  8 
"       typhoid,  12 
"  _    typhus,  13 
Filaria  medinensis,  100 

"        sanguinis,  99 
Fluid,  battery,  115 

diluting,  5 
Flea,  loi 
Food,  absorption  of,  142 

"       composition  of,  142 
Formula  of  Reuss,  92 
Fremitus,  pectoral,  31 
"         vocal,  31 
"         pericardial,  42 
"         pleuritic,  30 
"         Friedländer,  107 


1 66 


CLINICAL  DIAGNOSIS. 


Gallic  acid,     Pettenkoffer's    test 

for,  8i 
Gall-stones,  134 
Gastric  juice,  amount  of  acid  in, 

"  "       digesting   strength 

of,  59 
Gerhardt,  26 
Gibbus,  16 
Gmelin,  64 

Gonococci,  staining  of,  107 
Gram,  2,  106 
Grape  sugar,  81 

bismuth  test  for,  84 
Böttger's  test   for, 

84 
Fehling's  test  for, 

fermentation     test 

for,  81 
Moore's    test     for, 

82 
Mulder's   test   for, 

84 
Phenylhydrazin  test 

for,  84 
polarization       test 

for,  85 
quantitative       test 

for,  83 
reduction  tests  for, 

82 
Trommer's  test  for, 

82 
Gypsum,  76 

Haematin,  I 
Hsematoblasts,  3 
Hsematoidin  in  sputum,  35 
Haematuria,  79 
Haemin,  i 
Haemoglobin,  i 
Hemoglobinuria,  79 
Haser,  coefficient  of,  68 
Halla,  5 
Harrison,  17 
Harrison  furrow,  17 
Hay  em,  3,  5 
Heart,  apex  beat  of  the,  41 


Heart,  auscultation  of  the,  45 
"       inspection  and  palpation 
of,  41 

Heart,  movements  of  the,  42 
"       percussion  of  the,  43 
"       sounds  of  the,  45 

Heart  murmurs,  46 

"  "         diastolic,  46 

**  "         endocardial,  47 

"  "         pericardial,  47 

"     friction, 

.  47 
**  "         presystolic,  46 

"  "         strength  of,  46 

"  "         systolic,  47 

Heart   sounds,  metallic   46 
"  "         reduplication    of 

the,  46 
"  "         reduplication    of 

the  first,  46 

Hemialbumose,  78 

"  test  for,  78 

Hemianopsia,  124 

Hemiplegia,  iii 

Herpes  circinatus,  loi 
"        tonsurans,  loi 

Hippocrates,  30 

Hoffmann,  141 

Human  body,  table  of  the  weight 
and  height  of,  143 

Hydrobilirubin,  80 

"  test  for,  81 

Hydrocele,  92 

Hydrocephalus,  92 

Hydronephrosis,  94 

Hydro-quinone,  73 

Hydrothorax,  92 

Hypersesthesia,  108 

Hyperpyrexia,  9 

Hyphomycetes,  loi 

Hypochrondrium,  17 

Hypoxanthine,  73 

Indican,  73 

"         test  for,  74 
Inspiration,  duration  of  expira- 
tion and,  19 
Iron,  77 
Itch-insect,  100 


INDEX. 


167 


Kidneys,  67 
Koch,  106 
König,  141 
Kronecker,  57 

Laache,  5 

Lactose,  85 

Laryngoscopy,  37 

Larynx,  37 

"         auscultation  of  the,  37 
"        muscles  of  the,  38 
"        nerves  of  the,  38 
"        percussion  of  the,  37 

Law,  Ohm's,  116 

Leptothrix  forms,  103 

"  threads  in  sputum,  36 

Leube,  58 

Leucaemia,  6 

"  lymphatic,  6 

Leucine,  87 

Leuckart   99 

Leucocytes,  3 

"  pigment  containing, 

7 
"  in  sputum,  34 

"  in  urine,  89 

Leucocytosis,  6 

Leyden,  36 

Line,  anterior  axillary,  17 
"      costo-articular,  17 
"      mammary,  17 
*'      median,  17 
"      middle  axillary,  17 
"      parasternal,  17 
*'      posterior  axillary,  17 
"      scapula,  17 

Liver,  60 

"       position  of,  60 

Lordosis,  16 

Louse,  body,  loi 
"  crab,  loi 
"        head,  loi 

Lung,  apex  of  the,  21 
"      dulness  over  the,  23 
"      lower  border  of,  22 
"      movement  of  the,  22 
"       normal  boundaries  of,  21 
"      topography   of   the   lobes 
of  the,  22 


Lung,  total  capacity  of,  20 

"       upper  boundary  of,  21 
Lymphocytes,  3 
Lysis,  9 

Magnesium,  76 

Malaria,  14 

Malassez,  5 

Measles,  10 

Meinert,  137 

Melanine,  87 

test  for,  87 

Meltzer,  57 

Metabolism  and  nutrition,  136 

Microcytes,  2 

Micro-organisms,  7 

"  coloring  of,  104 

'*  Gram's  method 

of    staining, 
106 
"  in  sputum,  36 

*'  "  urine,  91 

Microsporon  furfur,  loi 

"  minutissimum,   102 

Mohrenheim,  16 

Mohrenheim's  groove,  16 

Moleschott,  5 

Monoplegia,  11 1 

Morbilli,  10 

Motility,  testing  the,  iii 

Motor   symptoms    of    irritation, 
112 

Müller,  F.,  141 

Narrowing,  expiratory,  ig 
Nematodes,  98 
Nerves,  cranial,  127 
"        dorsal,  131 
"        spinal,  129 
Nervi  thoracici  anteriores,  129 
Nervous  system,  most  important 

clinical  points  in  the  anatomy 

of  the,  124 
Nervus  abducens,  128 

"        accessorius,  128 

"        acusticus,  128 

"        axillary,  129 

"        cutaneus  medialis,  129 

"  "         medius,  129 


1 68 


CLINICAL   DIAGNOSIS. 


Nervus  dorsalis  scapulae,  129 
"        facialis,  128 
"        glossopharj'ngeus,  128 
"        h}^oglossus,  128  I 

"        ischiadicus,  131 
*'        medianus,  129 
"        musculocutaneus,  I2g 
"        oculomotorius,  127 
"        olfactorius,  127 
"        opticus,  127 
"        radialis,  130 
"        subscapulariS,  1 29 
"        suprascapularis,  129 
"        thoracicus  longus,  129 
"        trigeminus,  128 
"        trochlearis,  128 
"        ulnaris,  130 
"        vagus,  128 

Neumann,  65 

Neuralgia,  108 

Nothnagel,  64 

Nystagmus,  113 

CEsophagus,  56 

"  auscultation  of,  56 

"  length  of,  56 

Ohm's  law,  116 

Organs,  digestive  and  abdominal, 

55 
"        genito-urinary,  67 

Oidium  albicans,  102 
Otto,  5 

Ovarian  cyst,  94 
Oxyuris  vermicularis,  98 

Parsesthesia,  108 
Paradox  contraction,  123 
Paralysis,  in 

"         central,  126 

"         functional,  112 

"         peripheral,  126 
Paraplegia,  in,  126 
Parasites,  96 

"  animal,  96 

"  "        in  sputum,  36 

"  vegetable,  loi 

Paresis,  in 
Pectoriloquy,  30 
Pediculus  capitis,  loi 


Pediculus  pubis,  loi 

"         vestimenti,  loi 
Peptones,  79 

"  test  for,  79 

Percussion     note,     Biermer's 
change  of, 
26 
height     and 
depth    of, 
25 
Percussion  tone,    Gerhardt 's 
change  of,  26 
"  "      respiratory 

change  of,  26 
Phenols,  73 
Playfair,  137 
Plexus  brachialis,  129 
"        cervicalis,  129 
"       lumbalis,  131 
"        sacralis,  131 
Pneumonia  crouposa,  15 
Pneumonococcus  in  sputum,  36 

*'  staining  of,  107 

Poikilocytes,  2 
Pole,  active,  113 
"     different,  113 
"     indifferent,  113 
"     non-active,  113 
Potassium,  76 

'*  sulpho-cyanide  of,  73 

Propeptone,  78 
Protozoa,  loi 
Pseudoleucasmia,  6 
Pulex  irritans,  loi 
Pulse,  50 

capillary,  43 
"      dicrotic,  53 
"      frequency  of,  50 
"      fulness  of,  51 
"      hardness  of,  52 
"      hyperdicrotic,  53 
"       monocrotic,  53 
"       quickness,  51 
"       rhythm  of,  50 
"       size  of,  51 
"       subdicrotic,  53 
venous,  43,  53,  54 
Rales,  28 

"       crepitant,  29 


INDEX. 


169 


Rales,  dry,  29 
"       metallic,  29 
"       metallic  tinkling,  29 
"      moist,  29 
"      mucous,  29 
"      non-metallic,  29 
"       sub-crepitant,  29 
Reaction  of  degeneration,  120 
"  "  "       complete, 

120 
"  "  "    partial,  120 

Recurrent  fever,  13 
Red  blood  corpuscles,  increase  in 
number  of,  7 
nucleated,  3 
number  of,  5 
size  of,  I 
in  sputum, 35 
"  urine,  89 
Reflex  of  the  abdominal,  gluteal, 

and  scapular  regions,  122 
Reflex,  cremaster,  122 

"       exaggerated  tendon,   112 
"       extinguished,   123 
"       increased,  123 
"       patellar,  122 
"       pupil,  123 
"       sexual,  123 
"       skin,  121 

"       ot  the  sole  of  the  foot,  1 22 
"       of  the  tendo  Achillis,  122 
Reflexes,  tendon,  122 
Renk,  141 

Respiration,  Cheyne-Stokes,  20 
"  jerking,  27 

**  metamorphosing, 

27,  28 
**  normal  relation  be- 

tween   the     fre- 
quency of   pulse 
and,  18 
"  number  of,  18 

"  organs  of,  16 

'*  puerile,  27 

*'  retarding  of,  20 

"  systolic  vesicular,  27 

Reuss,  92 

Rhabdonema  strongyloides,  99 
Romberg,  iii 


Romberg,  symptom  of,  in 
Round  worms,  98 
Rubner,  139,  141 

Saliva,  56 

"      constituents  of,  56 

"      diastatic  ferment  of,  56 

"      reaction  of,  56 

"      specific  gravity  of,  56 
Sarcina  in  sputum,  36 
Scapula,  16 
Scarlatina,  10 
Scarlet-fever,  10 
Schizomycetes,  102 
Sense,  of  force,  no 

"       of  locality,  108,  109 
"       muscular,  109 
"       of  position,  in 
"       of  pressure,  109 
"       of  temperature,  no 
Sensibility,  108 

"         electro-cutaneous,  no 
"         to  pain,  no 
Sensitiveness  of  the  deep  parts, 

no 
Small-pox,  II 
Space,  interscapular,  17 
Spasm,  112 

"       clonic,   112 

"       tonic,  112 
Sodium,  76 
Sound,  clear,  21 

"       cracked-pot,  21,  23 

"       deep,   21 

•'       dull,  21 

"       empty,  21 

"       full,  21 

"       high,  21 

"       metallic,  21,  25 

"       non-tympanitic,  21 

"       tympanitic,  21,  24 
Spirillum,  103 
Spirometry,  20 
Spleen,  61 

"        position  of,  61 
Sputum,  32 

"         actinomycosis  in,  36 

"         alveolar  epithelium  in, 
34 


I/o 


CLINICAL   DIAGNOSIS. 


Sputum,  amount  of,  34 

"         animal  parasites  in,  36 
"        aspergillus    threads  in, 

36 
"    ,     bacilli  anthracis  in,  36 
"        black,  34 
"        bloody,  32 
"        blue-colored,  33 
"        bronchial  casts  in,  35 
"         Cholesterine  crystals  in, 

36 
"         Charcot-Leyden      crys- 
tals in,  36 
"         color  of,  33 
"         consistency  of,  33 
"         Curschmann's  spirals  in 

35 
"         cylindrical     epithelium 

in,  34 

"  elastic  fibres  in,  35 

"  fatty  acid  crystals  in,  35 

"  green,  33 

"  haematoidin  in,  35 

' '  leptothrix  threads  in,  36 

"  leucine  crystals  in,  36 

"  leucocytes  in,  34 

"  lung  parenchyma,  35 

"  micro-organisms  in,  36 

"  morphological  constitu- 
ents of,  34 

"  muco-purulent,  32 

"  mucous,  32 

' '  pavement       epithelium 

in,  34 
"         pneumonococcus  in,  36 
"         purulent,  32 
"  "  constituents 

of,  32 
"         purulo-mucous,  32 
"         reaction  of,  34 

red,  34 
"        red-blood  corpuscles  in, 

35 

"  sanguineo-mucous,  32 

"  sanguineo-serous,  32 

"  sarcinse  in,  36 

"  serous,  32 

"  smell  of,  33 

'*  tubercle  bacilli  in,  36 


Sputum,  tyrosine  crystals  in,  36 
"        yellow  ochre,  33,  34 

Stadium  decrementi,  9 
"        incrementi,  9 

Stage  of  incubation,  9 
"     prodromal,  9 

Sternum,  16 

Stokes,  20 

Stomach,  57 

"         digesting    strength    of, 

"         examination      of      the 

contents  of,  58 
"         percussion  of,  57 
"         position  of,  57 
"         size  of,  57 
"         tumors  of,  58 
Substances,  non-nitrogenous,  138 
Succussio  Hippocratis,  30 
Sugar  of  milk,  85 
Sulphuretted  hydrogen,  87 

"       test  for,  87 
System,  circulatory,  41 
"         nervous,  108 
"         urine-producing,  67 

Table,  dose,  144 
Tsenia  cucumerina,  97 
"      echinococcus,  97 
"      flavopunctata,  97 
"      nana,  97 
"       saginata    s.    mediocanel- 

lata,  97 
"      solium,  96 
Tape-worm,  96 
Teeth,  55 

milk,  55 
"       permanent,  55 
Teichmann's  crystals,  I 
Temperature,  8 

"  of  collapse,  8 

sub-febrile,  8 
Tension,  diminished,   iii 

"         increased,  iii 
Test  for  acetone,  85 
*'     "    albumen,  acetic    acid, 
and  ferrocya- 
nide  of  potas- 
sium test,  7§ 


INDEX. 


171 


Test  for  albumen,  biuret  test,  78 
"     "         "  heat  test,  77 

"     "         "  Heller's    test, 

< '     ♦  *         "  p  i  c  r  i  c-a  cid 

test,  78 
"     "    ammonia,  132 
"      '*    antipyrin,  89 
"      "    arsenic,  88 
"      "   bile,  Gmelin's  test,  80 
"      "      "     Pettenkoffer's  test, 

81 
"     "    blood,  guaiac  test,  80 
"     "        "       Heller's  test,  80 
"     "    bromine,  87 
"      "    carbolic  acid,  88 
"     "    cystine,  133 
"     "    diacetic  acid, 
"     "    drugs,  87 
"     "    grape     sugar, 

test,  84 
"     "    grape    sugar, 

test,  84 
"     "    grape    sugar, 

test,  83 
"     *'    grape    sugar, 

tiontest,  81 
"     "   grape     sugar,     Moore's 

test,  82 
"     "    grape    sugar,    Mulder's 

test,  84 
*'     "    grape  sugar,    Phenylhy- 
drazin test  for,  84 
"     "    grape    sugar,     polariza- 
tion test  for,  85 
"     "    grape    sugar,    reduction 

tests  for,  82 
"     "    grape  sugar,  Trommer's 

test,  82 
"     "    iodine,  87 
"     "   kairin,  89 
"     "   lead,  88 
"     "   lithium,  88 
"     "  melanine,  87 
"     "   murexide,  132 
"     "    nitric  acid,  88 
"     "    quinine,  88 
"     "    rhubarb,  89 
•*     "    salicylic  acid,  89 


86 
bismuth 
Böttger's 
Fehling's 

fermenta- 


Test  for  santonine,  89 
"     "    senna,  89 
"     "    sulphuretted   hydrogen, 

87 
"     "    tannin,  89 
"     "    thallin,  89 
"     '*    turpentine,  89 
"     "    uric  acid,  132 
"     "    xanthine,  133 
Testing  the  sensibility,  112 
Tetanus,  112 
Thoma,  5 

Thorax,  breadth  of,  17 
"         height  of,  17 
"         narrow,  18 
"         percussion  of,  21 
"         size  of,  17 
Thrush  fungus,  102 
Touch  sense,  108 
Transudations  and  exudations, 92 
Transudations    and    exudations, 

albumen  in,  92 
Transudations    and    exudations, 

contents  of,  93 
Transudations    and    exudations, 

specific  gravity  of,  92 
Traube,  half-moon  shaped  space 

of,  57 
Trematodes,  100 
Tremors,  112 
Trichina  spiralis,  99 
Tricocephalus  dispar,  98 
Trichomonas  intestinalis,  loi 

"  vaginalis,   loi 

Triple  phosphates,  76 
Trychophyton  tonsurans,  loi 
Typhus  abdominalis,  12 

"       exanthematicus,  13 
Typhoid  fever,  12 
Typhus  fever,  13 
Tyrosine,  87 

Tuberclebacilli,  Ehrlich'smethod 
of  staining,  105 
"  "       in  sputum,  36 

"  "      in  Weigert- 

Koch's  fluid  for  staining,  106 

Urea,  70 
"       test  for,  70 


1/2 


CLINICAL  DIAGNOSIS. 


Uric  acid,  test  for,  132 
Urine,  67 

acetone  in,  85 
albumen  in,  77 
amido-caproic  acid  in,  87 
amido  -  hydroparacumaric 

acid  in,  87 
ammonia  in,  76 
amount  of,  68 
animal  parasites  in,  gi 
antipyrin  in,  89 
arsenic  in,  88 
bile  in,   80,  81 
blood  in,  79 

"       "  guaiac  test  for, 
80 
blood    in.    Heller's    test 

for,  80 
blood    in,    microscopical 

test  for,  80 
bromine  in,  87 
calcium  in,  76 
carbolic  acid  in,  88 
carbonic  acid  in,  75 
casts  in,  90 

chrysophanic  acid  in,  89 
cystine  in,  87 
dextrose  in,  81 
diacetic  acid  in,  86 
drugs  in,  87 
epithelium  in,  89,  90 
fat  in,  87 
grape  sugar  in,  81 
g^'psum  in,  76 
heniialbumose  in,  78 
hydrochloric  acid  in,  74 
inorganic  constituents  of, 

74 

inosite  in,  85 
iodine  in,  87 
iron  in,  77 
kairin  in,  89 
lactose  in,  85 
lead  in,  88 
leucocytes  in,  89 
lithium  in,  88 
magnesium  in,  76 
melanine  in,  87 
mercur)'  in,  88 


Urine,  micro-organisms  in,  91 
**       nitric  acid  in,  88 
"        normal  constituents  of ,  70 
"       organic  sediment  in,  89 
"       pathological  constituents 

of,  77   . 

"  peptones  in,  79 

"  phosphoric  acid  in,  75 

"  potassium  in,  76 

"  propeptone  in,  78 

"  quinine  in,  88 

"  reaction  of,  68 

"  red  blood  corpuscles  in,  83 

"  rhubarb  in,  89 

"  salicylic  acid  in,  8g 

"  santonin  in,  89 

*'  senna  in,  89 

"  sodium  in,  76 

"  specific  gravity  of,  68 

"  sugar  of  milk  in,  85 

' '  sulphuretted  hydrogen  in, 

^7     .       .     . 
"        sulphuric  acid  in,  75 

"       tannin  in,  89 

"       thallin  in,  89 

"       turpentine  in,  89 

"       tyrosine  in,  87 

Urobilin,  80 

Valves,  aortic,  45 

"  mitral,  45 

"         pulmonar)%  45 

"         tricuspid,  45 
Varicella,  12 
Variola,  11 
Varioloid,  ii 
Variolois,  II 
Vertebral  column,  16 
Vibrio,  or  curved  rod,  102 
Vocal  cords,  closure  of  the,  38 

"         "       paralysis  of  the,  39 

"         "       tension  of  the,  38 

"  "       -widening  of  the,  38 

Voice,  37 

"       auscultation  of,  29 

"       bass,  37 

"       closed  nasal,  37 

"        diphthonic,  37 

"       falsetto,  37 


INDEX. 


173 


Voice,  hoarse,  37 
"       metallic,  30 
"       open  nasal,  37 
"       tripartite,  37 
"       want  of,  37 
"       weak,  37 
V.  Voit,  137,  140,  141 
Vomitus,   blood  in,  59 

' '         carbonate  of  ammonia 
in,   60 
epithelium  in,  60 
gall  in,  60 
leucocytes  in,  60 
mucus  in,  59 
oidium  albicans,  60 
remains  of  food  in,  60 
sarcinae  in,  60 
schizomycetes  in,  60 
swallowed     saliva    in, 

59. 
urea  in,  60 

yeast  cells  in,  60 

Voussure,  42 


Weigert,  106 

Welker,  5 

Westphal,  123 

White  blood  corpuscles,  3 

"  "  "    large  mono- 

nuclear, 3 
"    large    poly- 
nuclear,  3 
"  "  "    number  of, 5 

Wintrich,  26 
Worms,  flat,  100 
"         round,   98 
'*         small  thread,  98 
"         tape,  96 
"         whip,  98 
Wunderlich,  8 

Xanthine,  73 

"         test  for,  133 

Yeast  fungi,  102 

Zeiss,  5 


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The  saucy  little  book  has  made  a  hit. — Am.  Pract.  and Ne-ws^  Oct.  30,  1886. 

This  book  is  rich  in  bombast,  but  destitute  of  any  practical  value. — Medical  Bulletin., 
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The  quaint  and  sarcastic  remarks  strike  the  reader  at  once  and  cannot  fail  to  enable  him 
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Monthly.,  Feb.,  18S6. 

This  beyond  doubt  is  as  contemptible  a  book  as  was  ever  written  for  medical  men 

The  style  to  be  expected  from  an  ardent  partisan  with  little  knowledge  and  bad  taste. — 
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This  book  should  be  in  the  hands  of  every  practitioner. — Med.  Press.,  May,  1886. 

A  most  admirable  treatise  for  study  by  hospital  stewards  and  others  connected  with  the 
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We  wish  that  every  physician  in  the  land  could  be  supplied  with  this  book. — Ala.  M. 
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If  the  principles  proclaimed  in  this  little  book  were  rigidly  carried  out  by  all  surgeons 


now  WE  TREAT  WOUNDS  TO-DAY. 

there  would  be  fewer  deaths  in  hospital  and  private  practice. — Chicago  M.  and  S.  Jour, 
and  Exam..,  Nov.,  1886. 

A  book  which  we  cannot  too  highly  praise If  read  and  studied  by  surgeons  in 

general  would  save  much  suffering  and  many  lives. — Pacißc  M.  and  S.  Jour,  and  West- 
ern Lancet.,  April,  1886. 

A  prominent  example  of  superlatively  bad  stj-le  and  sophistical  reasoning. — Sozithern 
Practitioner.,  Dec,  1886. 

A  spicy  little  book  written  in  the  characteristic  stj'le  of  the  true-born  American  citizen. 
— Canada  M.  a7id  S.  Jour. y  July,  1886. 

The  author  is  evidently  a  bright  and  interesting  man,  judging  from  the  way  in  which 
he  handles  the  pen.  His  style  is  racy  and  singularly  attractive. — Cincinnati  L.  and  C.^ 
March  8,  1886. 

The  laconic  style  of  the  author  and  the  sledge-hammer  way  in  which  he  deals  with 
the  follies  of  those  who  persist  in  the  treatment  of  wounds  by  the  old  methods  has  a 
fascination  about  it  that  charms  and  Interests  the  reader  to  the  end. — Indiana  Med. 
/our..  May,  1886. 

The  author  shoots  his  facts  like  bullets'  against  the  mark.  Without  waste  of  time  or 
space. —  The  Med.  Library ,  1886. 

The  author  has  done  his  work  well Language  terse  and  aphorisms  pungent. — 

N.  Y.  Med.  Record.  March  20, 1886. 

The  plan  of  the  volume  is  capital.  Everj^  page  abounds  in  practical  hints  from  an  evi- 
dently practical  surgeon. — London  Med.  Press  and  Circ,  June  30,  1886. 

The  quaint  and  often  sarcastic  style  of  the  book  makes  the  sound  principles  it  advocates 
only  the  more  impressive. — North-western  Lancet.,  Feb.,  1886. 

Dr.  Morris  has  a  style  all  his  own  in  medical  literature,  and  impresses  what  he  says. — 
Med.  and  Surg.  Rep.,  Nov.  6,  1886. 

There  is  so  much  superficial,  so-called  antiseptic  work  being  done,  that  such  a  clean-cut, 
positive,  detailed  setting  forth  of  what  constitutes  real  antiseptic  work  as  this  is,  is  called 
for. — Annals  of  Surgery ,  Feb.,  1887. 

A  valuable  book  which  commends  itself  to  ^x&ry  intelligent  reader,  and  which  no  student 
of  the  ars  chirurgica  can  afford  to  be  without. — Progress   Nov.,  1886. 

"  The  deep-laid  scheme  ""  of  the  author  to  make  a  disturbance  with  this  little  work  has 
proved  effective.  We  prophesy-  numerous  editions  and  a  correspondingly  thankful  pro- 
fession.— Med.  Register^  Feb.  12,  1887. 

The  author  is  well  acquainted  with  his  subject. — London  Med.  Record,  Aug.  16,  1886. 


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